Exam 1 Foundation
When a patient is grimacing, what assessment statement or question would be most beneficial for
identifying the underlying cause of the nonverbal communication?
"Did you lose something?"
"You appear to be having pain."
"I will turn off the lights and let you rest."
"May I get you something to relieve your tension?" - ANS "You appear to be having pain."Yes; this is the
most therapeutic response.
The best approach for a nurse who is performing an assessment on a patient from an ethnic group the
nurse knows nothing about is to
a. use the information the nurse already knows about the other ethnic groups that may be similar to the
patient's group to come up with assessment questions.
b. ask the same questions the nurse typically asks of all patients and not deviate from the questions on
the assessment form.
c. ask the patient to explain what he or she believes his or health problem is and what he or she thinks
caused it.
d. ask the patient to help the nurse understand anything about the patient's ethnic group that may have
a bearing on the patient's health care needs. - ANS ask the patient to help the nurse understand
anything about the patient's ethnic group that may have a bearing on the patient's health care needs.
Yes! The best strategy is to approach the situation with humility and admit a lack of knowledge about
the patient's ethnic group. Include the patient!
A nurse recognizes the importance of active listening as a way to show the nurse cares. Which one of
the following actions by the nurse describes active listening?
a. Sitting at the bedside and listening to the patient talk while inserting an IV
b. Sitting in a chair facing a patient and making a mental note of the major points of the conversation
c. Listening to what the patient says and what he means while she conducts her early morning
assessment
,d. Engaging both the patient and the family members while taking careful notes of the conversation -
ANS Sitting in a chair facing a patient and making a mental note of the major points of the conversation
The nurse receives a change of shift report on five assigned patients and reviews prescriptions,
treatments, and medications scheduled. Based on this information, the nurse chooses which patient to
assess first. Which process of critical thinking best describes the nurse's action?
Problem solving
Decision making
Judgement
Reasoning - ANS decision making
The nurse assesses a patient's oxygenation saturation and the patient has a lower than normal (88% on
room air) pulse oximetry reading. Which action by the nurse results from accurately employing the
critical thinking skill of analysis?
a. Allowing the patient to be alone to rest more comfortably
b. Discussing adaptations needed for daily activities with the patient
c. Lowering the head of the patient's bed
d. Raising the head of the patient's bed - ANS Raising the head of the patient's bed
A nurse has just realized a medication error has been made. The nurse immediately assesses the patient
and reports the error to the nurse manager and primary care provider. Which characteristic of the
nursing profession is the nurse demonstrating?
Autonomy
Collaboration
Accountability
Altruism - ANS Accountability
The nurse is assessing a patient with a sudden onset of abdominal pain. During the assessment, the
nurse considers similar presentations and underlying pathophysiology related to the patient's
,manifestations. Which critical thinking skill should the nurse use first to determine the cause of the
patient's abdominal pain?
Evaluation
Interpretation
Reflection
Inference - ANS Interpretation
Which nursing theory of caring describes how the nurse's presence in the nurse-patient relationship
transcends the physical and materiel world, facilitating the development of a higher sense of self by the
patient?
Swanson's Middle Range Theory of Caring
Madeline Leininger's Cultural Care Theory
Watson's Theory of Human Science and Human Care
Travel bee's Human-to-Human Relationship Model - ANS Watson's Theory of Human Science and Human
Care
The nurse is working at an extended care facility and is caring for an 85-year-old male patient who was
just admitted to the facility. The patient is experiencing frequent bouts of stool incontinence, has
significant body odor, and needs assistance to clean up when incontinent. What is the most appropriate
response for the nurse?
a. Communicate frustration through facial expressions without verbalizing disgust
b. Ask the patient if he wants to be cleaned up
c. Immediately assess the patient while verbalizing the importance of bathing daily
d. Assist the patient without expressing frustration with the situation - ANS Assist the patient without
expressing frustration with the situation Yes; focusing on the patient's needs is the nurse's first priority.
Physical assessment of a patient requires the nurse to function most often in which area of a patient's
space?
Personal
, Social
Intimate
Public - ANS Intimate. Yes; 0-1.5 feet is an appropriate distance to conduct most physical assessment
processes.
Which one of the following nursing diagnoses is appropriately written?
Risk for Infection related to septic shock
Chronic Pain related to osteoarthritis
Noncompliance related to an inability to access care
Risk for Bleeding related to sickle cell anemia - ANS Noncompliance related to an inability to access care
This NANDA is written correctly.
Which intervention can the nurse initiate independently while providing patient care?
Auscultating lung sounds
Ordering a blood transfusion
Ordering dietary changes for a patient.
Removal of a chest tube - ANS Auscultating lung sounds
Which statement best illustrates a characteristic of goals within a care plan?
Goals are measurable and specific.
The nurse evaluates if goals are met, not met, or in progress.
Goals are global and broader than outcomes.
Goal attainment can be measured by identifying interventions. - ANS Goals are measurable and specific.
Which action by the day-shift nurse provides objective data that enables the night-shift nurse to
complete an evaluation of a patient's short-term goals?
Encouraging the patient to share observations from the day.
When a patient is grimacing, what assessment statement or question would be most beneficial for
identifying the underlying cause of the nonverbal communication?
"Did you lose something?"
"You appear to be having pain."
"I will turn off the lights and let you rest."
"May I get you something to relieve your tension?" - ANS "You appear to be having pain."Yes; this is the
most therapeutic response.
The best approach for a nurse who is performing an assessment on a patient from an ethnic group the
nurse knows nothing about is to
a. use the information the nurse already knows about the other ethnic groups that may be similar to the
patient's group to come up with assessment questions.
b. ask the same questions the nurse typically asks of all patients and not deviate from the questions on
the assessment form.
c. ask the patient to explain what he or she believes his or health problem is and what he or she thinks
caused it.
d. ask the patient to help the nurse understand anything about the patient's ethnic group that may have
a bearing on the patient's health care needs. - ANS ask the patient to help the nurse understand
anything about the patient's ethnic group that may have a bearing on the patient's health care needs.
Yes! The best strategy is to approach the situation with humility and admit a lack of knowledge about
the patient's ethnic group. Include the patient!
A nurse recognizes the importance of active listening as a way to show the nurse cares. Which one of
the following actions by the nurse describes active listening?
a. Sitting at the bedside and listening to the patient talk while inserting an IV
b. Sitting in a chair facing a patient and making a mental note of the major points of the conversation
c. Listening to what the patient says and what he means while she conducts her early morning
assessment
,d. Engaging both the patient and the family members while taking careful notes of the conversation -
ANS Sitting in a chair facing a patient and making a mental note of the major points of the conversation
The nurse receives a change of shift report on five assigned patients and reviews prescriptions,
treatments, and medications scheduled. Based on this information, the nurse chooses which patient to
assess first. Which process of critical thinking best describes the nurse's action?
Problem solving
Decision making
Judgement
Reasoning - ANS decision making
The nurse assesses a patient's oxygenation saturation and the patient has a lower than normal (88% on
room air) pulse oximetry reading. Which action by the nurse results from accurately employing the
critical thinking skill of analysis?
a. Allowing the patient to be alone to rest more comfortably
b. Discussing adaptations needed for daily activities with the patient
c. Lowering the head of the patient's bed
d. Raising the head of the patient's bed - ANS Raising the head of the patient's bed
A nurse has just realized a medication error has been made. The nurse immediately assesses the patient
and reports the error to the nurse manager and primary care provider. Which characteristic of the
nursing profession is the nurse demonstrating?
Autonomy
Collaboration
Accountability
Altruism - ANS Accountability
The nurse is assessing a patient with a sudden onset of abdominal pain. During the assessment, the
nurse considers similar presentations and underlying pathophysiology related to the patient's
,manifestations. Which critical thinking skill should the nurse use first to determine the cause of the
patient's abdominal pain?
Evaluation
Interpretation
Reflection
Inference - ANS Interpretation
Which nursing theory of caring describes how the nurse's presence in the nurse-patient relationship
transcends the physical and materiel world, facilitating the development of a higher sense of self by the
patient?
Swanson's Middle Range Theory of Caring
Madeline Leininger's Cultural Care Theory
Watson's Theory of Human Science and Human Care
Travel bee's Human-to-Human Relationship Model - ANS Watson's Theory of Human Science and Human
Care
The nurse is working at an extended care facility and is caring for an 85-year-old male patient who was
just admitted to the facility. The patient is experiencing frequent bouts of stool incontinence, has
significant body odor, and needs assistance to clean up when incontinent. What is the most appropriate
response for the nurse?
a. Communicate frustration through facial expressions without verbalizing disgust
b. Ask the patient if he wants to be cleaned up
c. Immediately assess the patient while verbalizing the importance of bathing daily
d. Assist the patient without expressing frustration with the situation - ANS Assist the patient without
expressing frustration with the situation Yes; focusing on the patient's needs is the nurse's first priority.
Physical assessment of a patient requires the nurse to function most often in which area of a patient's
space?
Personal
, Social
Intimate
Public - ANS Intimate. Yes; 0-1.5 feet is an appropriate distance to conduct most physical assessment
processes.
Which one of the following nursing diagnoses is appropriately written?
Risk for Infection related to septic shock
Chronic Pain related to osteoarthritis
Noncompliance related to an inability to access care
Risk for Bleeding related to sickle cell anemia - ANS Noncompliance related to an inability to access care
This NANDA is written correctly.
Which intervention can the nurse initiate independently while providing patient care?
Auscultating lung sounds
Ordering a blood transfusion
Ordering dietary changes for a patient.
Removal of a chest tube - ANS Auscultating lung sounds
Which statement best illustrates a characteristic of goals within a care plan?
Goals are measurable and specific.
The nurse evaluates if goals are met, not met, or in progress.
Goals are global and broader than outcomes.
Goal attainment can be measured by identifying interventions. - ANS Goals are measurable and specific.
Which action by the day-shift nurse provides objective data that enables the night-shift nurse to
complete an evaluation of a patient's short-term goals?
Encouraging the patient to share observations from the day.
