Lewis's Medical-Surgical Nursing: Assessment

1. The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patients input. The patient states, How is this different from what the doc2r does? Whch response would be most appropriate4 the nurse 2 make? a. The role of the nurse is 2 administer medications and other treatments prescribed by your doc2r. b. The nurses job is 2 help the doc2r by collecting in4mation and communicating any problems that occur. c. Nurses per4m many of the same procedures as the doc2r, but nurses are with the patients 4 a longer time than the doc2r. d. In addition 2 caring 4 you while you are sick, the nurses will assist you 2 develop an individualized plan 2 maintain your health. ANS: D This response is consistent with the American Nurses Association (ANA) definition of nursing, whch describes the role of nurses in promoting health. The other responses describe some of the dependent and collaborative functions of the nursing role but do not accurately describe the nurses role in the health care system. DIF: Cognitive Level: Understand (comprehension) REF: 3 2P: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. The nurse describes 2 a student nurse how 2 use evidence-based practice guidelines when caring 4 patients. Whch statement, if made by the nurse, would be the most accurate? a. Inferences from clinical research studies are used as a guide. b. Patient care is based on clinical judgment, experience, and traditions. c. Data are evaluated 2 show that the patient outcomes are consistently met. d. Recommendations are based on research, clinical expertise, and patient preferences. ANS: D Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician expertise. Clinical judgment based on the nurses clinical experience is part of EBP, but clinical decision making should also incorporate current research and research-based guidelines. Evaluation of patient outcomes is important, but interventions should be based on research from randomized control studies with a large number of subjects. DIF: Cognitive Level: Remember (knowledge) REF: 11 2P: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 3. The nurse teaches a student nurse about how 2 apply the nursing process when providing patient care. Whch statement, if made by the student nurse, indicates that teaching was successful? a. The nursing process is a scientific-based method of diagnosing the patients health care problems. b. The nursing process is a problem-solving 2ol used 2 identify and treat patients health care needs. c. The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans. d. The nursing process is used primarily 2 explain nursing interventions 2 other health care professionals. ANS: B The nursing process is a problem-solving approach 2 the identification and treatment of patients problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing process is in patient care, not 2 establish nursing theory or explain nursing interventions 2 other health care professionals. DIF: Cognitive Level: Understand (comprehension) REF: 7 2P: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 4. A patient has been admitted 2 the hospital 4 surgery and tells the nurse, I do not feel com4table leaving my children with my parents. Whch action should the nurse take next? a. Reassure the patient that these feelings are common 4 parents. b. Have the patient call the children 2 ensure that they are doing well. c. Gather more data about the patients feelings about the child-care arrangements. d. Call the patients parents 2 determine whether adequate child care is being provided. ANS: C Since a complete assessment is necessary in order 2 identify a problem and choose an appropriate intervention, the nurses first action should be 2 obtain more in4mation. The other actions may be appropriate, but more assessment is needed be4e the best intervention can be chosen. DIF: Cognitive Level: Apply (application) REF: 6-7 OBJ: Special Questions: Prioritization 2P: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip. Whch nursing diagnosis is most appropriate? a. Impaired physical mobility related 2 left-sided paralysis b. Risk 4 impaired tissue integrity related 2 left-sided weakness c. Impaired skin integrity related 2 altered circulation and pressure d. Ineffective tissue perfusion related 2 inability 2 move independently ANS: C The patients major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer. The nurse is able 2 treat the cause of altered circulation and pressure by frequently repositioning the patient. Although left-sided weakness is a problem 4 the patient, the nurse cannot treat the weakness. The risk 4 diagnosis is not appropriate 4 this patient, who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is. DIF: Cognitive Level: Apply (application) REF: 7-9 2P: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related 2 excessive diaphoresis. Whch outcome would the nurse recognize as most appropriate 4 this patient? a. Patient has a balanced intake and output. b. Patients bedding is changed when it becomes damp. c. Patient understands the need 4 increased fluid intake. d. Patients skin remains cool and dry throughout hospitalization. ANS: A This statement gives measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was resolved. DIF: Cognitive Level: Apply (application) REF: 7-9 2P: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the evaluation phase of the nursing process? a. 2 determine if interventions have been effective in meeting patient outcomes b. 2 document the nursing care plan in the progress notes of the medical record c. 2 decide whether the patients health problems have been completely resolved d. 2 establish if the patient agrees that the nursing care provided was satisfac2ry ANS: A Evaluation consists of determining whether the desired patient outcomes have been met and whether the nursing interventions were appropriate. The other responses do not describe the evaluation phase. DIF: Cognitive Level: Understand (comprehension) REF: 7-9 2P: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 8. The nurse interviews a patient while completing the health his2ry and physical examination. What is the purpose of the assessment phase of the nursing process? a. 2 teach interventions that relieve health problems b. 2 use patient data 2 evaluate patient care outcomes c. 2 obtain data with whch 2 diagnose patient problems d. 2 help the patient identify realistic outcomes 4 health problems ANS: C During the assessment phase, the nurse gathers in4mation about the patient 2diagnose patient problems. The other responses are examples of the planning, intervention, and evaluation phases of the nursing process. DIF: Cognitive Level: Understand (comprehension) REF: 7-9 2P: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 9. Whch nursing diagnosis statement is written correctly? a. Altered tissue perfusion related 2 heart failure b. Risk 4 impaired tissue integrity related 2 sacral redness c. Ineffective coping related 2 response 2 biopsy test results d. Altered urinary elimination related 2 urinary tract infection ANS: C This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patients response 2 a health problem that can be treated by nursing. The use of a medical diagnosis as an etiology (as in the responses beginning Altered tissue perfusion and Altered urinary elimination) is not appropriate. The response beginning Risk 4 impaired tissue integrity uses the defining characteristic as the etiology. DIF: Cognitive Level: Understand (comprehension) REF: 7 2P: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 10. The nurse admits a patient 2 the hospital and develops a plan of care. What components should the nurse include in the nursing diagnosis statement? a. The problem and the suggested patient goals or outcomes b. The problem with possible causes and the planned interventions c. The problem, its cause, and objective data that support the problem d. The problem with an etiology and the signs and symp2ms of the problem ANS: D When writing nursing diagnoses, this 4mat should be used: problem, etiology, and signs and symp2ms. The subjective, as well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the nursing diagnosis statement. DIF: Cognitive Level: Remember (knowledge) REF: 8-9 2P: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 11. A nurse is caring 4 a patient with heart failure. Whch task is appropriate 4 the nurse 2 delegate 2 experienced unlicensed assistive personnel (UAP)? a. Moni2r 4 shortness of breath or fatigue after ambulation. b. Instruct the patient about the need 2 alternate activity and rest. c. Obtain the patients blood pressure and pulse rate after ambulation. d. Determine whether the patient is ready 2 increase the activity level. ANS: C UAP education includes accurate vital sign measurement. Assessment and patient teaching require registered nurse education and scope of practice and cannot be delegated. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation 2P: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment ...................................................................................................CONTINUE.