Integrated Exam 2 Practice Questions /
Comprehensive Update Actual Questions &
Answers (A+ Guide Solution)
Terms in this set (111)
Which of the following items D. Client feel nauseated
of subjective data would be
documented in the medical Rationale:
record by the nurse? Subjective data includes the client's sensations, feelings, and
perception of health status. Subjective data can only be
verified by the affected person. Options 1, 2, and 3
A. Client's face is pale
represent objective data that can be detected by the nurse
B. Cervical lymph or measured against an accepted norm.
nodesare palpable
C. Nursing
assistantreports client
refused lunch
D. Client feel nauseated
,A nurse explains to a student D. Nurse rapidly reset priorities for client care based on a
that the nursing process is a change in the client's condition
dynamic process. Which of
the following actions by the Rationale:
nurse best demonstrates this The nursing process is characterized by unique properties
concept during the work that enable it to respond to the changing health status of the
client. Options 1, 2, and 3 are appropriate nursing care
shift?
measures, but do not demonstrate the dynamic nature of the
nursing process.
A. Nurse and client
agreeupon health care goals
for the client
B. Nurse reviews
theclient's history on the
medical record
C. Nurse explains to
theclient the purpose of each
administered medication D.
Nurse rapidly reset priorities
for client care based on a
change in the client's
condition
,The rehabilitation nurse D. Long-term goals
wishes to make the following
entry into a client's plan of Rationale:
care: "Client will reestablish a Long-term goals describe changes in client behavior expected
pattern of daily bowel over a time frame greater than one week. They are usually
designed to restore normal functioning in a problem area and
movements without straining
are helpful to other healthcare workers who care for the
within two months." The client, often in a variety of settings.
nurse would write this
statement under which
section of the plan of care?
A. Nursing
diagnosis/problem list B.
Nursing orders
C. Short-term goals
D. Long-term goals
, The nursing diagnosis is Risk B. Skin will remain intact and without redness during hospital stay
for impaired skin integrity
related to immobility and Rationale:
pressure secondary to pain The human response/label is what needs to change (Risk for
and presence of a cast. impaired skin integrity). The label suggests the outcomes. In
this case, "skin will remain intact" is the desired outcome
Which of the following
for a client at risk for impaired skin integrity. Option 1
desired outcomes should addresses immobility. Option 3 addresses pain. Option 4 is
the nurse include in the care an intervention.
plan?
A. Client will be able
toturn self by day 3
B. Skin will remain
intactand without redness
during hospital stay C. Client
will state pain relieved
within 30 minutes after
medication D. Pressure will
be prevented by
repositioning client every
2 hours
Comprehensive Update Actual Questions &
Answers (A+ Guide Solution)
Terms in this set (111)
Which of the following items D. Client feel nauseated
of subjective data would be
documented in the medical Rationale:
record by the nurse? Subjective data includes the client's sensations, feelings, and
perception of health status. Subjective data can only be
verified by the affected person. Options 1, 2, and 3
A. Client's face is pale
represent objective data that can be detected by the nurse
B. Cervical lymph or measured against an accepted norm.
nodesare palpable
C. Nursing
assistantreports client
refused lunch
D. Client feel nauseated
,A nurse explains to a student D. Nurse rapidly reset priorities for client care based on a
that the nursing process is a change in the client's condition
dynamic process. Which of
the following actions by the Rationale:
nurse best demonstrates this The nursing process is characterized by unique properties
concept during the work that enable it to respond to the changing health status of the
client. Options 1, 2, and 3 are appropriate nursing care
shift?
measures, but do not demonstrate the dynamic nature of the
nursing process.
A. Nurse and client
agreeupon health care goals
for the client
B. Nurse reviews
theclient's history on the
medical record
C. Nurse explains to
theclient the purpose of each
administered medication D.
Nurse rapidly reset priorities
for client care based on a
change in the client's
condition
,The rehabilitation nurse D. Long-term goals
wishes to make the following
entry into a client's plan of Rationale:
care: "Client will reestablish a Long-term goals describe changes in client behavior expected
pattern of daily bowel over a time frame greater than one week. They are usually
designed to restore normal functioning in a problem area and
movements without straining
are helpful to other healthcare workers who care for the
within two months." The client, often in a variety of settings.
nurse would write this
statement under which
section of the plan of care?
A. Nursing
diagnosis/problem list B.
Nursing orders
C. Short-term goals
D. Long-term goals
, The nursing diagnosis is Risk B. Skin will remain intact and without redness during hospital stay
for impaired skin integrity
related to immobility and Rationale:
pressure secondary to pain The human response/label is what needs to change (Risk for
and presence of a cast. impaired skin integrity). The label suggests the outcomes. In
this case, "skin will remain intact" is the desired outcome
Which of the following
for a client at risk for impaired skin integrity. Option 1
desired outcomes should addresses immobility. Option 3 addresses pain. Option 4 is
the nurse include in the care an intervention.
plan?
A. Client will be able
toturn self by day 3
B. Skin will remain
intactand without redness
during hospital stay C. Client
will state pain relieved
within 30 minutes after
medication D. Pressure will
be prevented by
repositioning client every
2 hours
