NUR 170 EXAM 1 – 4 QUESTIONS & ANSWERS
what is a medical diagnosis? - Answers :A medical diagnosis focuses on the disease or
pathology that affects the patient.
what is the nursing diagnosis? - Answers :concentrates on the patient's responseto the
illness or life circumstance, which can be either a physiological or psychological
response.
Can anxiety and pain be a medical and nursing diagnosis? - Answers :true.
What is documentation? - Answers :it needs to be complete and obtain apporiate and
essential Information.
We do this when we document on the wrong chart or make an error in the clinical
record. - Answers :Draw one line through the documentation and intial it
What is an incident report? - Answers :when this report is written it should not be
documented in the client's chart
What is protect the client's rights? - Answers :The primary goal of the nurse as advocate
What is a nursing diagnosis? - Answers :Part of the nursing process that contains the
problem, etiology, and signs and symptoms that require nursing interventions
What is implementation of interventions? - Answers :This is the phase in the nursing
process where the nurse puts the plan to work in order to obtain established goals
what is evaluation? - Answers :drawing a conclusion about the client's outcomes after
the implementation of interventions
What is primary care? - Answers :Point of entry to healthcare or gateway to health care
services
The Delaware Board of Nursing is here to protect: - Answers :an organization that
provides rules and regulations in DE to protect the client or population from nursing
What is chronological order? - Answers :documentation in the patients's chart is written
in this order
what is a telephone order? - Answers :This order must be repeated back to the
healthcare provided to ensure accuracy
What is tertiary care? - Answers :type of healthcare that contains complicated
diagnostic services; rehab
,What is Maslow's hierarchy of needs? - Answers :The concept used to prioritize care for
a client that include safety and love/ belonging
What is the PIE charting? Problem intervention and evaluation - Answers :This is a type
of charting nurses document in the chart for nurses notes
What is HIPPA? - Answers :This is a federal legislative department to protect the
privacy of clients records
What is the ANA Code of Ethics for Nurses? - Answers :guidelines developed for all
nurses regarding ethical and professional behavior
what is giving report - Answers :This is done at the change of shift or transfer of a client
What is a verbal order? - Answers :This is an order given by the healthcare provider
during an emergency and there is no time to write it
What is SMART?
1. Specific
2. Measurable
3. Appropriate
4. Realistic
5. Timely - Answers :This acronym stands for what the nursing goal should consist of
What is PES? - Answers :problem, etiology, signs and symptoms
The client asks the nurse for a copy of their medical record. The nurse knows that this
right is part of which regulation.
A. The patient self-determination act.
B. HIPAA
C. The uniform anatomical gift act.
D. The Americans with disabilities act. - Answers :B. HIPPA
Which communication strategies should the nurse use when working w/ a client who
has difficulty speaking d/t weakness?
A. Encourage the client to speak quickly
B. Ask yes and no questions when able
C. Have the client use a communication board
D. Repeat what the client said to verify the message
E. Use a pen and paper to communicate client needs.
F. Encourage verbal communication to strengthen the client's voice. - Answers :B. Ask
yes and no questions when able
D. Repeat what the client said to verify the message
C. Have the client use a communication board
E. Use a pen and paper to communicate client needs.
,A post-op pt says "Don't touch me, I will take care of myself". Which response is
therapeutic?
A. Fine, I won't touch you.
B. Let's work together so you can do things for yourself.
C. I have to change your dressing so I have to touch you.
D. If that's what you want but I need to report this to the surgeon. - Answers :B. Let's
work together so you can do things for yourself.
A nurse performing a home assessment on an older client having weakness would be
concerned about which unsafe finding?
A. Nonskid surfaces on slippers
B. Nonskid backing on small rugs
C. Electrical cords taped to the floor
D. Bath mats on the shower stall floor
E. Electrical appliances and cords near the sink.
F. Full bathroom on the second floor - Answers :E. Electrical appliances and cords near
the sink.
F. Full bathroom on the second floor
The nurse understands that which are judgemental statements.
A. I don't think you need to do that.
B. Tell me about making that decision.
C. I'm not sure that's what is best for you.
D. When did you first notice you felt that way?
E. I would like to be sure I understood what you said.
F. It will be fine. We all feel that way sometimes. - Answers :A. I don't think you need to
do that.
C. I'm not sure that's what is best for you.
F. It will be fine. We all feel that way sometimes.
The nurse is teaching a pt. about home safety. Which recommendations would they
include?
A. Remove wall-to-wall carpeting.
B. Use nightlights during nighttime.
C. Place handrails in bathtubs and showers.
D. Check staircase railings for secureness and sturdiness.
E. Place scatter rugs on hardwood floors and at the bottom of a staircase.
F. Use extension cords for additional lamps to provide adequate lighting. - Answers :C.
Place handrails in bathtub and showers.
B. Use nightlights during nighttime.
D. Check staircase railings for secureness and sturdiness
When discussing a health care plan with an Amish client, the nurse should perform
which actions?
A. Speak only to the client.
B. Avoid using medical terms.
, C. Maintain adequate personal space.
D. Use complex scientific terminology.
E. Stand close to the client and speak softly.
F. Establish a helping relationship - Answers :C. Maintain adequate personal space.
B. Avoid using medical terms
F. Establish a helping relationship.
The nurse understands that personal health information can be disclosed in which
situations?
A. Compliance with legal proceedings.
B. For research purposes in limited circumstances.
C. To a family member or significant other in an emergency.
D. To nonessential medical personnel involved in client care.
E. To appropriate military if a client is a member of the armed forces.
F. During lunch break with colleagues who work in another unit. - Answers :A.
Compliance with legal proceedings
B. For research purposes in limited circumstances
C. To a family member or significant other in an emergency
E. To appropriate military, if a client is a member of the armed forces
The hospice nurse has established a helping relationship with the client + family. Which
actions are most appropriate?
A. Encouraging family discussions of feelings.
B. Accepting the family's expressions of anger.
C. Restricting client visit to scheduled hospital visiting hours.
D. Facilitating the use of spiritual practices identified by the family.
E. Keeping the family informed of changes in the client's condition.
F. Making decisions for the family during the difficult moments. - Answers :A.
Encouraging family discussions of feelings
E. Keeping the family informed of the changes in the client's condition
B. Accepting the family's expressions of anger
D. Facilitating the use of spiritual practices identified by the family
A nurse is teaching a client how to self-administer tube feedings at home. The client
expresses concern. Best response?
A. Does your family know about this concern you have?
B. Is there a family member or friend that is willing to help you?
C. Do you want me to prescribe home visits from the nurse for you?
D. Let's talk about what makes it hard for you to perform this procedure. - Answers :D.
Let's talk about what makes it hard for you to perform this procedure.
Which nursing actions can result in disciplinary action by state boards of nursing?
A. Release of client health information to a client's neighbor.
B. Delegation of a dressing change to UAP.
C. Release of client health information to the client's durable POA.
D. Admin. of a routine immunization that resulted in an allergic reaction.
what is a medical diagnosis? - Answers :A medical diagnosis focuses on the disease or
pathology that affects the patient.
what is the nursing diagnosis? - Answers :concentrates on the patient's responseto the
illness or life circumstance, which can be either a physiological or psychological
response.
Can anxiety and pain be a medical and nursing diagnosis? - Answers :true.
What is documentation? - Answers :it needs to be complete and obtain apporiate and
essential Information.
We do this when we document on the wrong chart or make an error in the clinical
record. - Answers :Draw one line through the documentation and intial it
What is an incident report? - Answers :when this report is written it should not be
documented in the client's chart
What is protect the client's rights? - Answers :The primary goal of the nurse as advocate
What is a nursing diagnosis? - Answers :Part of the nursing process that contains the
problem, etiology, and signs and symptoms that require nursing interventions
What is implementation of interventions? - Answers :This is the phase in the nursing
process where the nurse puts the plan to work in order to obtain established goals
what is evaluation? - Answers :drawing a conclusion about the client's outcomes after
the implementation of interventions
What is primary care? - Answers :Point of entry to healthcare or gateway to health care
services
The Delaware Board of Nursing is here to protect: - Answers :an organization that
provides rules and regulations in DE to protect the client or population from nursing
What is chronological order? - Answers :documentation in the patients's chart is written
in this order
what is a telephone order? - Answers :This order must be repeated back to the
healthcare provided to ensure accuracy
What is tertiary care? - Answers :type of healthcare that contains complicated
diagnostic services; rehab
,What is Maslow's hierarchy of needs? - Answers :The concept used to prioritize care for
a client that include safety and love/ belonging
What is the PIE charting? Problem intervention and evaluation - Answers :This is a type
of charting nurses document in the chart for nurses notes
What is HIPPA? - Answers :This is a federal legislative department to protect the
privacy of clients records
What is the ANA Code of Ethics for Nurses? - Answers :guidelines developed for all
nurses regarding ethical and professional behavior
what is giving report - Answers :This is done at the change of shift or transfer of a client
What is a verbal order? - Answers :This is an order given by the healthcare provider
during an emergency and there is no time to write it
What is SMART?
1. Specific
2. Measurable
3. Appropriate
4. Realistic
5. Timely - Answers :This acronym stands for what the nursing goal should consist of
What is PES? - Answers :problem, etiology, signs and symptoms
The client asks the nurse for a copy of their medical record. The nurse knows that this
right is part of which regulation.
A. The patient self-determination act.
B. HIPAA
C. The uniform anatomical gift act.
D. The Americans with disabilities act. - Answers :B. HIPPA
Which communication strategies should the nurse use when working w/ a client who
has difficulty speaking d/t weakness?
A. Encourage the client to speak quickly
B. Ask yes and no questions when able
C. Have the client use a communication board
D. Repeat what the client said to verify the message
E. Use a pen and paper to communicate client needs.
F. Encourage verbal communication to strengthen the client's voice. - Answers :B. Ask
yes and no questions when able
D. Repeat what the client said to verify the message
C. Have the client use a communication board
E. Use a pen and paper to communicate client needs.
,A post-op pt says "Don't touch me, I will take care of myself". Which response is
therapeutic?
A. Fine, I won't touch you.
B. Let's work together so you can do things for yourself.
C. I have to change your dressing so I have to touch you.
D. If that's what you want but I need to report this to the surgeon. - Answers :B. Let's
work together so you can do things for yourself.
A nurse performing a home assessment on an older client having weakness would be
concerned about which unsafe finding?
A. Nonskid surfaces on slippers
B. Nonskid backing on small rugs
C. Electrical cords taped to the floor
D. Bath mats on the shower stall floor
E. Electrical appliances and cords near the sink.
F. Full bathroom on the second floor - Answers :E. Electrical appliances and cords near
the sink.
F. Full bathroom on the second floor
The nurse understands that which are judgemental statements.
A. I don't think you need to do that.
B. Tell me about making that decision.
C. I'm not sure that's what is best for you.
D. When did you first notice you felt that way?
E. I would like to be sure I understood what you said.
F. It will be fine. We all feel that way sometimes. - Answers :A. I don't think you need to
do that.
C. I'm not sure that's what is best for you.
F. It will be fine. We all feel that way sometimes.
The nurse is teaching a pt. about home safety. Which recommendations would they
include?
A. Remove wall-to-wall carpeting.
B. Use nightlights during nighttime.
C. Place handrails in bathtubs and showers.
D. Check staircase railings for secureness and sturdiness.
E. Place scatter rugs on hardwood floors and at the bottom of a staircase.
F. Use extension cords for additional lamps to provide adequate lighting. - Answers :C.
Place handrails in bathtub and showers.
B. Use nightlights during nighttime.
D. Check staircase railings for secureness and sturdiness
When discussing a health care plan with an Amish client, the nurse should perform
which actions?
A. Speak only to the client.
B. Avoid using medical terms.
, C. Maintain adequate personal space.
D. Use complex scientific terminology.
E. Stand close to the client and speak softly.
F. Establish a helping relationship - Answers :C. Maintain adequate personal space.
B. Avoid using medical terms
F. Establish a helping relationship.
The nurse understands that personal health information can be disclosed in which
situations?
A. Compliance with legal proceedings.
B. For research purposes in limited circumstances.
C. To a family member or significant other in an emergency.
D. To nonessential medical personnel involved in client care.
E. To appropriate military if a client is a member of the armed forces.
F. During lunch break with colleagues who work in another unit. - Answers :A.
Compliance with legal proceedings
B. For research purposes in limited circumstances
C. To a family member or significant other in an emergency
E. To appropriate military, if a client is a member of the armed forces
The hospice nurse has established a helping relationship with the client + family. Which
actions are most appropriate?
A. Encouraging family discussions of feelings.
B. Accepting the family's expressions of anger.
C. Restricting client visit to scheduled hospital visiting hours.
D. Facilitating the use of spiritual practices identified by the family.
E. Keeping the family informed of changes in the client's condition.
F. Making decisions for the family during the difficult moments. - Answers :A.
Encouraging family discussions of feelings
E. Keeping the family informed of the changes in the client's condition
B. Accepting the family's expressions of anger
D. Facilitating the use of spiritual practices identified by the family
A nurse is teaching a client how to self-administer tube feedings at home. The client
expresses concern. Best response?
A. Does your family know about this concern you have?
B. Is there a family member or friend that is willing to help you?
C. Do you want me to prescribe home visits from the nurse for you?
D. Let's talk about what makes it hard for you to perform this procedure. - Answers :D.
Let's talk about what makes it hard for you to perform this procedure.
Which nursing actions can result in disciplinary action by state boards of nursing?
A. Release of client health information to a client's neighbor.
B. Delegation of a dressing change to UAP.
C. Release of client health information to the client's durable POA.
D. Admin. of a routine immunization that resulted in an allergic reaction.
