Nursing: Semester 1 Unit 1 Exam
____________ is being completely truthful with patients; nurses must not
withhold the whole truth from clients even when it may lead to patient distress. -
ANS - veractiy
\______________ is probably the only role about which there is agreement as to
what it means and how we do it.
A. Caregiving
B. Educating
C. Managing
D. Advocating - ANS - Caregiving
(The role of the nurse as caregiver has engendered the least amount of
controversy. This role has been thoroughly documented, not only in writing but
also through art, since early times. Nurses and nursing leaders agree that this is
their primary role. )
\____________________is the central component of effective leadership - ANS -
communication
\______________is concerned with treating people equitably, fairly, and
appropriately - ANS - justice
\"Activity intolerance r/t imbalance between oxygen supply and demand aeb
verbal reports of fatigue, exertional dyspnea, and abnormal heart rate in response
to activity"
Is this two step or three step diagnosis and point out the PES - ANS - Three step
Problem: activity intolerance
Etiology: r/t imbalance between oxygen supply and demand
Symptoms: aeb verbal reports of fatigue, exertional dyspnea, and abnormal heart
rate in response to activity
\"Deficient Knowledge r/t unfamiliarity with information about the nursing process
and nursing diagnosis aeb verbalization of lack of understanding"
,Name the Problem, Etiology, and Symptom - ANS - Problem: "Deficient
knowledge"
Etiology: unfamiliarity with information about the nursing process
Symptom: verbalization of lack of understanding
\** NCLEX QUESTION
The nurse is assessing a 32-year-old female client who delivered a newborn three
hours ago, and notes that the clients; temperature is 100.7 degrees F. What is the
nurses' priority action ?
A. notify the physician
B. Document the findings
C. Retake the temperature in half an hour
D. Increase hydration and encourage oral fluids - ANS - D.
The key words priority action tell you this will be the implemention aspect of the
nursing process
\** NCLEX QUESTION:
A 82- year old female has been admitted to the hospital with pneumonia and a
UTI. She has been too weak to get out of bed for the past 3 days. As the nurse is
giving her a bed bath, the nurse notices some new redness over her sacrum.
What should the nurse do first?
A. Use a finger to apply pressure to the reddened area
B. Notify the physician
C. Apply a dressing to the area for cushioning
D. Document your observations - ANS - A.
The key words "do first" tells you this is the assessment part of the nursing
process. Answer A " use a finger to apply pressure to the reddened area will help
you asses the issues...it will tell you if this is a pressure ulcer and what grade.
,\*** NCLEX question:
You are caring for a high risk pregnant client who is in a life threatening situation.
The fetus is also at high risk for death. Clinical decisions are being made that
concern you because some of these treatments and life saving measures
promote the pregnant woman's life at the same time that they significantly
jeopardize the fetus' life and viability and other decisions can preserve the fetus's
life at the expense of the pregnant woman's life. Which role of the nurse is the
priority at this time?
Case manager
Collaborator
Coordinator of care
Advocacy - ANS - Advocacy
The priority role of the nurse is advocacy. The nurse must serve as the advocate
for both the fetus and the mother at risk as the result of this ethical dilemma
where neither option is desirable. As an advocate, the nurse would seek out
resources and people, such as the facility's ethicist or the ethics committee, to
resolve this ethical dilemma.
\****Ideally the etiology (r/t statement), or cause, of the nursing diagnosis is
something that can be treated
Collaboratively or Independently by a nurse - ANS - Independently by a nurse
\***Collective Data - ANS - -Using a systematic & ongoing process
-Categorizing data
-Recording data (Observation, Interview & Examination)
\***NCLEX QUESTION
It's a busy day at the hospital, and the nurse just got her client assignments for
the day. Which of the following clients should the nurse asses first?
A. a clients with a total knee replacement two-day postoperative complaining of a
HA
B. a client who requires a complex dressing change
C. An irritated client who is anxious and ready for discharge
, D. An asthmatic client with difficulty of breathing - ANS - D. An asthmatic client
with difficulty of breathing
(Remember ABC's come first...ask yourself who is going to die first)
\***The related to or cause guides which part of the nursing process? - ANS -
intervention
It is crucial to discover what is causing the problem. If you known what is causing
the problem you can intervene effectiviely
\**Define clinical judgment - ANS - an interpretation of conclusion about a
patient's needs, concerns, or health problems, and/or the decision to take action
(or not), use or modify standard approaches, or improvise new ones as deemed
appropriate by the patient's response
\**Example of clinical judgment : - ANS - nursing process
\**Readiness for Enhanced Knowledge is an example of what type of nursing
diagnosis - ANS - Wellness
\*What type of thinking does a novice nurse typically rely on?
A. analytical
B. Intuitive
C. Narrative
D. All of the above - ANS - A. analytical
\2 ways to treat a health problem - ANS - collaborative or independently
\3 care coordination models - ANS - -social
-medically oriented
-integrated
\3 goals of care coordination - ANS - -improve and optimize care
-promote health and independence
-reduce unnecessary utilization of health care services
\5 Attributes of care coordination - ANS - 1. Inter-organizational and
inter-professional team (includes patient and family)
2. Communication and information exchange
3. Proactive plan of care with goals
4. Set of purposeful activities
5. Proactive follow up
____________ is being completely truthful with patients; nurses must not
withhold the whole truth from clients even when it may lead to patient distress. -
ANS - veractiy
\______________ is probably the only role about which there is agreement as to
what it means and how we do it.
A. Caregiving
B. Educating
C. Managing
D. Advocating - ANS - Caregiving
(The role of the nurse as caregiver has engendered the least amount of
controversy. This role has been thoroughly documented, not only in writing but
also through art, since early times. Nurses and nursing leaders agree that this is
their primary role. )
\____________________is the central component of effective leadership - ANS -
communication
\______________is concerned with treating people equitably, fairly, and
appropriately - ANS - justice
\"Activity intolerance r/t imbalance between oxygen supply and demand aeb
verbal reports of fatigue, exertional dyspnea, and abnormal heart rate in response
to activity"
Is this two step or three step diagnosis and point out the PES - ANS - Three step
Problem: activity intolerance
Etiology: r/t imbalance between oxygen supply and demand
Symptoms: aeb verbal reports of fatigue, exertional dyspnea, and abnormal heart
rate in response to activity
\"Deficient Knowledge r/t unfamiliarity with information about the nursing process
and nursing diagnosis aeb verbalization of lack of understanding"
,Name the Problem, Etiology, and Symptom - ANS - Problem: "Deficient
knowledge"
Etiology: unfamiliarity with information about the nursing process
Symptom: verbalization of lack of understanding
\** NCLEX QUESTION
The nurse is assessing a 32-year-old female client who delivered a newborn three
hours ago, and notes that the clients; temperature is 100.7 degrees F. What is the
nurses' priority action ?
A. notify the physician
B. Document the findings
C. Retake the temperature in half an hour
D. Increase hydration and encourage oral fluids - ANS - D.
The key words priority action tell you this will be the implemention aspect of the
nursing process
\** NCLEX QUESTION:
A 82- year old female has been admitted to the hospital with pneumonia and a
UTI. She has been too weak to get out of bed for the past 3 days. As the nurse is
giving her a bed bath, the nurse notices some new redness over her sacrum.
What should the nurse do first?
A. Use a finger to apply pressure to the reddened area
B. Notify the physician
C. Apply a dressing to the area for cushioning
D. Document your observations - ANS - A.
The key words "do first" tells you this is the assessment part of the nursing
process. Answer A " use a finger to apply pressure to the reddened area will help
you asses the issues...it will tell you if this is a pressure ulcer and what grade.
,\*** NCLEX question:
You are caring for a high risk pregnant client who is in a life threatening situation.
The fetus is also at high risk for death. Clinical decisions are being made that
concern you because some of these treatments and life saving measures
promote the pregnant woman's life at the same time that they significantly
jeopardize the fetus' life and viability and other decisions can preserve the fetus's
life at the expense of the pregnant woman's life. Which role of the nurse is the
priority at this time?
Case manager
Collaborator
Coordinator of care
Advocacy - ANS - Advocacy
The priority role of the nurse is advocacy. The nurse must serve as the advocate
for both the fetus and the mother at risk as the result of this ethical dilemma
where neither option is desirable. As an advocate, the nurse would seek out
resources and people, such as the facility's ethicist or the ethics committee, to
resolve this ethical dilemma.
\****Ideally the etiology (r/t statement), or cause, of the nursing diagnosis is
something that can be treated
Collaboratively or Independently by a nurse - ANS - Independently by a nurse
\***Collective Data - ANS - -Using a systematic & ongoing process
-Categorizing data
-Recording data (Observation, Interview & Examination)
\***NCLEX QUESTION
It's a busy day at the hospital, and the nurse just got her client assignments for
the day. Which of the following clients should the nurse asses first?
A. a clients with a total knee replacement two-day postoperative complaining of a
HA
B. a client who requires a complex dressing change
C. An irritated client who is anxious and ready for discharge
, D. An asthmatic client with difficulty of breathing - ANS - D. An asthmatic client
with difficulty of breathing
(Remember ABC's come first...ask yourself who is going to die first)
\***The related to or cause guides which part of the nursing process? - ANS -
intervention
It is crucial to discover what is causing the problem. If you known what is causing
the problem you can intervene effectiviely
\**Define clinical judgment - ANS - an interpretation of conclusion about a
patient's needs, concerns, or health problems, and/or the decision to take action
(or not), use or modify standard approaches, or improvise new ones as deemed
appropriate by the patient's response
\**Example of clinical judgment : - ANS - nursing process
\**Readiness for Enhanced Knowledge is an example of what type of nursing
diagnosis - ANS - Wellness
\*What type of thinking does a novice nurse typically rely on?
A. analytical
B. Intuitive
C. Narrative
D. All of the above - ANS - A. analytical
\2 ways to treat a health problem - ANS - collaborative or independently
\3 care coordination models - ANS - -social
-medically oriented
-integrated
\3 goals of care coordination - ANS - -improve and optimize care
-promote health and independence
-reduce unnecessary utilization of health care services
\5 Attributes of care coordination - ANS - 1. Inter-organizational and
inter-professional team (includes patient and family)
2. Communication and information exchange
3. Proactive plan of care with goals
4. Set of purposeful activities
5. Proactive follow up
