In the clinical reasoning process, the nurse sets & weighs the criteria, examines
alternatives & performs which of the following before implementing a plan?
a.Reexamines the purpose for making the decision.
b.Consults the client and family members to determine their view of the criteria.
c.Identifies and considers various means for reaching the outcomes.
d.Determines the logical course of action should intervening problems arise.
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d.Correct. It is important to project what problems might interfere with the
plan and have appropriate responses prepared to prevent the
interferences.
According to Piaget's theory of cognitive development, the movement from
intuitive reasoning to logical reasoning in school-age children is called the
concrete operations phase. Which is an example of this phase?
,a.A science-fair project comparing how fast different objects fall from a set height
b.Feeling responsible for wishing that a sibling would go away, and now that sibling is
ill and hospitalized
c.Understanding how geometric figures might fit into a futuristic and idealistic world
d.Learning to ride a bike
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a.A science-fair project comparing how fast different objects fall from a set
height Rationale: Correct. During the phase of concrete operations,
children change from egocentric interactions to cooperative interactions.
They also develop an increased understanding of concepts that are
associated with specific objects. They learn to add and subtract and
understand cause-and-effect relationships.
An adult child brings a parent to an agency with signs and symptoms of potential
fluid retention (e.g., high blood pressure, swollen feet) possibly related to
excessive sodium intake. Further nursing assessment indicates inadequate food
storage and preparation techniques in the home. Which would be the most
appropriate nursing diagnosis?
a.Readiness for Enhanced Family Coping
b.Disabled Family Coping
c.Impaired Parenting
d.Caregiver Role Strain
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a.Readiness for Enhanced Family Coping Rationale: Correct. Presenting to
the clinic indicates the family is probably ready to face the health
challenges caused by the previous activities.
The nurse notices that when an 80-year-old man rises from a seated position, the
client uses both arms to push himself up, and also "rocks" back and forth before
,finally standing. What is the most appropriate intervention for this client?
a.Suggest a referral to physical therapy for strengthening exercises.
b.Suggest a waist restraint to remind the client not to stand by himself.
c.Praise the client for his attempts to remain independent.
d.Assist the client to rise by grasping both his shoulders and pulling forward.
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a.Suggest a referral to physical therapy for strengthening exercises.
Rationale: Correct. The client has loss of muscle strength. Strengthening
exercises will improve his mobility and lessen the possibility of a fall.
The nurse knows that the study of growth and development is an exploration of
which of the following?
a.Physical changes of the growing child
b.Increasing complexity of function and skill progression of the growing child
c.Environmental factors such as family, religion, and culture of the growing child
d.Physical developments and the increasing level and progression of function and skill
of the growing child
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d.Physical developments and the increasing level and progression of
function and skill of the growing child Rationale: Correct. The study of
growth (physical) and development (function and skills) is correct because
the answer needs to have both components to be complete.
Which of the following behaviors is most representative of the nursing diagnosis
phase of the nursing process?
a.Identifying major problems or needs
b.Organizing data in the client's family history
c.Establishing short-term and long-term goals
, d.Administering an antibiotic
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a.Correct. Identifying problems/needs is part of nursing diagnosis. For
example, a client with difficulty breathing would have Impaired Gas
Exchange related to constricted airways as manifested by shortness of
breath (dyspnea) as a nursing diagnosis.
Because a severely injured middle-aged client informed the nurse that he did not
have any immediate family members, the nurse contacted extended family
members. Which of the following is most representative of extended family
members?
a.Grandparents, aunts and uncles
b.Parents and spouse
c.Children who no longer live at home
d.Roommates and close family friends
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a.Grandparents, aunts and uncles Rationale: Correct. Grandparents, aunts,
and uncles are considered extended family members.
A nurse is presenting teaching sessions to a group of residents in a home forlong-
term physical rehabilitation. Which client exhibits the highestmotivation?
a. An individual who has been struggling with following nursing directives regarding
discharge goals
b. A client who has been there the longest and is a great"coach" for newcomers
c. The client who has just moved in and is already waiting for discharge
d. A client who is excited to learn about his new prosthesis
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alternatives & performs which of the following before implementing a plan?
a.Reexamines the purpose for making the decision.
b.Consults the client and family members to determine their view of the criteria.
c.Identifies and considers various means for reaching the outcomes.
d.Determines the logical course of action should intervening problems arise.
Give this one a try later!
d.Correct. It is important to project what problems might interfere with the
plan and have appropriate responses prepared to prevent the
interferences.
According to Piaget's theory of cognitive development, the movement from
intuitive reasoning to logical reasoning in school-age children is called the
concrete operations phase. Which is an example of this phase?
,a.A science-fair project comparing how fast different objects fall from a set height
b.Feeling responsible for wishing that a sibling would go away, and now that sibling is
ill and hospitalized
c.Understanding how geometric figures might fit into a futuristic and idealistic world
d.Learning to ride a bike
Give this one a try later!
a.A science-fair project comparing how fast different objects fall from a set
height Rationale: Correct. During the phase of concrete operations,
children change from egocentric interactions to cooperative interactions.
They also develop an increased understanding of concepts that are
associated with specific objects. They learn to add and subtract and
understand cause-and-effect relationships.
An adult child brings a parent to an agency with signs and symptoms of potential
fluid retention (e.g., high blood pressure, swollen feet) possibly related to
excessive sodium intake. Further nursing assessment indicates inadequate food
storage and preparation techniques in the home. Which would be the most
appropriate nursing diagnosis?
a.Readiness for Enhanced Family Coping
b.Disabled Family Coping
c.Impaired Parenting
d.Caregiver Role Strain
Give this one a try later!
a.Readiness for Enhanced Family Coping Rationale: Correct. Presenting to
the clinic indicates the family is probably ready to face the health
challenges caused by the previous activities.
The nurse notices that when an 80-year-old man rises from a seated position, the
client uses both arms to push himself up, and also "rocks" back and forth before
,finally standing. What is the most appropriate intervention for this client?
a.Suggest a referral to physical therapy for strengthening exercises.
b.Suggest a waist restraint to remind the client not to stand by himself.
c.Praise the client for his attempts to remain independent.
d.Assist the client to rise by grasping both his shoulders and pulling forward.
Give this one a try later!
a.Suggest a referral to physical therapy for strengthening exercises.
Rationale: Correct. The client has loss of muscle strength. Strengthening
exercises will improve his mobility and lessen the possibility of a fall.
The nurse knows that the study of growth and development is an exploration of
which of the following?
a.Physical changes of the growing child
b.Increasing complexity of function and skill progression of the growing child
c.Environmental factors such as family, religion, and culture of the growing child
d.Physical developments and the increasing level and progression of function and skill
of the growing child
Give this one a try later!
d.Physical developments and the increasing level and progression of
function and skill of the growing child Rationale: Correct. The study of
growth (physical) and development (function and skills) is correct because
the answer needs to have both components to be complete.
Which of the following behaviors is most representative of the nursing diagnosis
phase of the nursing process?
a.Identifying major problems or needs
b.Organizing data in the client's family history
c.Establishing short-term and long-term goals
, d.Administering an antibiotic
Give this one a try later!
a.Correct. Identifying problems/needs is part of nursing diagnosis. For
example, a client with difficulty breathing would have Impaired Gas
Exchange related to constricted airways as manifested by shortness of
breath (dyspnea) as a nursing diagnosis.
Because a severely injured middle-aged client informed the nurse that he did not
have any immediate family members, the nurse contacted extended family
members. Which of the following is most representative of extended family
members?
a.Grandparents, aunts and uncles
b.Parents and spouse
c.Children who no longer live at home
d.Roommates and close family friends
Give this one a try later!
a.Grandparents, aunts and uncles Rationale: Correct. Grandparents, aunts,
and uncles are considered extended family members.
A nurse is presenting teaching sessions to a group of residents in a home forlong-
term physical rehabilitation. Which client exhibits the highestmotivation?
a. An individual who has been struggling with following nursing directives regarding
discharge goals
b. A client who has been there the longest and is a great"coach" for newcomers
c. The client who has just moved in and is already waiting for discharge
d. A client who is excited to learn about his new prosthesis
Give this one a try later!
