NUR 218 EXAM 2 QUESTIONS AND 100%
CORRECT ANSWERS
Nursing diagnoses consider the underlying etiology, needs, potential concerns, and
patient response to a patient's medical diagnosis, so the two types of diagnoses are
interrelated. Medical diagnoses are not imbedded or derived from medical diagnoses
because that would limit the scope of assessment and care that is provided for patients.
Nurses consider the medical diagnosis as one aspect of concern when identifying an
actual or potential health problem and the patient's response, so medical diagnoses are
relevant, but not the focus of nursing diagnoses.
A patient has just experienced a cardiac arrest on the unit. The nurse has implemented
the acute care plan for management of code situations. What is the next step the nurse
should take?
a. Resume all interventions for previously identified nursing diagnoses.
b. Perform the steps of the nursing process related to the patient's current condition.
c. Seek physician input related to updating the nursing diagnosis statements.
d. Evaluate the success of the acute care plan for management of the cardiac arrest. -
ANSWER Perform the steps of the nursing process related to the patient's current
condition.
The patient's condition requires immediate performance of the lifesaving steps of the
nursing process. All other answers are secondary actions. The nurse later resumes all
interventions for previously identified nursing diagnoses and evaluates the success of
the acute care plan for management of the cardiac arrest. Nurses do not seek the input
of the physician for creation of nursing diagnoses.
What signs and symptoms would the nurse appropriately cluster for a patient with
extreme anxiety? (Select all that apply.)
a. Denies any difficulty falling asleep
b. Elevated pulse rate auscultated at 140 BPM
,c. Continuous foot tapping throughout intake interview
d. Demonstrates how to give insulin self-injection without hesitation
e. Patient states, "I feel nervous all the time, especially when I am alone." - ANSWER b,
c, e
An elevated pulse rate, continuous toe tapping, and verbalizing nervousness are
consistent with extreme anxiety and should be clustered together. Ease of falling asleep
and being able to focus on a challenging task, such as giving an injection, are not
indicative of a patient experiencing a high level of anxiety.
The hospice nurse believes the nursing diagnosis chronic sorrow is significant in the
recovery process of patients recently experiencing a loss. What is required to support
the addition of new nursing diagnoses to the NANDA-I taxonomy?
a. Clinical research and data collection
b. Changes in patient status and life experience
c. Anecdotal nursing experiences
d. Patient requests - ANSWER Clinical research and data collection
Clinical research, documenting the study findings of nurses who practice using the
nursing process, is required to support the addition of new nursing diagnoses to the
NANDA-I taxonomy. Nursing diagnoses are developed through comprehensive research
and data collection to support the eventual confirmation of actual nursing diagnostic
statements.
The nurse has just received a postoperative patient to the floor postureteral stone
manipulation. Choose the priority nursing diagnosis.
a. Risk for urinary retention r/t general anesthesia and trauma to ureter
,b. Pain, acute r/t recent surgical procedure and verbalization of pain of 4 on scale 0-10
c. Risk for bleeding r/t surgical site injury
d. Comfort, impaired r/t inability to urinate and verbalization "I am beginning to feel full"
- ANSWER Risk for urinary retention r/t general anesthesia and trauma to ureter
The combination of general anesthesia and possible trauma to the ureter places the
patient at risk for urinary retention. The other options are secondary to the risk for
urinary retention. The "Risk for urinary retention r/t general anesthesia and trauma to
ureter" is early and more pressing than "Comfort, impaired r/t inability to urinate and
verbalization 'I am beginning to feel full.'"
The relationship of the medical diagnosis to the nursing diagnosis is
a. the medical diagnosis is embedded within the nursing diagnostic statement.
b. nursing diagnoses are driven by/derived from the medical diagnosis.
c. the medical diagnosis is not relevant to the nursing diagnosis.
d. the medical and nursing diagnoses should complement each other. - ANSWER the
medical and nursing diagnoses should complement each other.
Nursing diagnoses take into consideration a patient's attitudes, strengths, and
resources—not just the medical problems identified—which are critical for planning
holistic, individualized care. Medical diagnoses are not written within the nursing
diagnosis statements. Nursing diagnoses are not derived from medical diagnoses.
There is relevance of nursing diagnoses to medical diagnoses.
An example of implementation of evidenced practice by the nurse would be the nurse
a. initiates a new policy protocol for the removal of c-collars and bed board restraints of
the emergency department patient based on empirical research results.
b. watched a news report on a new procedure for chest tube removal and implements
the procedure on the patient needing chest tubes removed.
c. saw a physician perform a manipulation for vertigo related to inner ear problems and
, decides to utilize the manipulation for the current patient experiencing vertigo.
d. is assisting a physician with conscious sedation during a procedure and is asked to
perform outside the nursing scope of practice. - ANSWER initiates a new policy protocol
for the removal of c-collars and bed board restraints of the emergency department
patient based on empirical research results.
New research findings are continuously resulting in policy changes for nursing practice.
The nurse should embrace the new policy and procedures based on empirical research
results. The other options are dangerous practices for nurses, are outside their scope
of practice, and/or are not based on sound research results.
The clustering of data is significant to the nursing diagnoses step because clustering of
data will
a. show the nurse assessment is complete for this patient.
b. move the nurse toward accurate planning for the symptoms in clustered data.
c. group the data of similar problems and aid in accurate nursing diagnosis
identification.
d. organize the data for clear assessment so further assessment can occur. - ANSWER
group the data of similar problems and aid in accurate nursing diagnosis identification.
After collecting and reviewing all of the assessment data, the nurse looks for patterns
and related data to support specific nursing diagnoses. This process is referred to as
clustering data. Clustering involves organizing patient assessment data into groupings
with similar underlying causes. The nurse looks for cues among the data that support
the diagnosis of a problem. Clustering data is not associated with assessment.
Symptoms are not the only data clustered. Data are clustered during diagnosis, not
assessment.
A flat macular hemorrhage is called a(n):
a. purpura
b. ecchymosis
c. petechiae
CORRECT ANSWERS
Nursing diagnoses consider the underlying etiology, needs, potential concerns, and
patient response to a patient's medical diagnosis, so the two types of diagnoses are
interrelated. Medical diagnoses are not imbedded or derived from medical diagnoses
because that would limit the scope of assessment and care that is provided for patients.
Nurses consider the medical diagnosis as one aspect of concern when identifying an
actual or potential health problem and the patient's response, so medical diagnoses are
relevant, but not the focus of nursing diagnoses.
A patient has just experienced a cardiac arrest on the unit. The nurse has implemented
the acute care plan for management of code situations. What is the next step the nurse
should take?
a. Resume all interventions for previously identified nursing diagnoses.
b. Perform the steps of the nursing process related to the patient's current condition.
c. Seek physician input related to updating the nursing diagnosis statements.
d. Evaluate the success of the acute care plan for management of the cardiac arrest. -
ANSWER Perform the steps of the nursing process related to the patient's current
condition.
The patient's condition requires immediate performance of the lifesaving steps of the
nursing process. All other answers are secondary actions. The nurse later resumes all
interventions for previously identified nursing diagnoses and evaluates the success of
the acute care plan for management of the cardiac arrest. Nurses do not seek the input
of the physician for creation of nursing diagnoses.
What signs and symptoms would the nurse appropriately cluster for a patient with
extreme anxiety? (Select all that apply.)
a. Denies any difficulty falling asleep
b. Elevated pulse rate auscultated at 140 BPM
,c. Continuous foot tapping throughout intake interview
d. Demonstrates how to give insulin self-injection without hesitation
e. Patient states, "I feel nervous all the time, especially when I am alone." - ANSWER b,
c, e
An elevated pulse rate, continuous toe tapping, and verbalizing nervousness are
consistent with extreme anxiety and should be clustered together. Ease of falling asleep
and being able to focus on a challenging task, such as giving an injection, are not
indicative of a patient experiencing a high level of anxiety.
The hospice nurse believes the nursing diagnosis chronic sorrow is significant in the
recovery process of patients recently experiencing a loss. What is required to support
the addition of new nursing diagnoses to the NANDA-I taxonomy?
a. Clinical research and data collection
b. Changes in patient status and life experience
c. Anecdotal nursing experiences
d. Patient requests - ANSWER Clinical research and data collection
Clinical research, documenting the study findings of nurses who practice using the
nursing process, is required to support the addition of new nursing diagnoses to the
NANDA-I taxonomy. Nursing diagnoses are developed through comprehensive research
and data collection to support the eventual confirmation of actual nursing diagnostic
statements.
The nurse has just received a postoperative patient to the floor postureteral stone
manipulation. Choose the priority nursing diagnosis.
a. Risk for urinary retention r/t general anesthesia and trauma to ureter
,b. Pain, acute r/t recent surgical procedure and verbalization of pain of 4 on scale 0-10
c. Risk for bleeding r/t surgical site injury
d. Comfort, impaired r/t inability to urinate and verbalization "I am beginning to feel full"
- ANSWER Risk for urinary retention r/t general anesthesia and trauma to ureter
The combination of general anesthesia and possible trauma to the ureter places the
patient at risk for urinary retention. The other options are secondary to the risk for
urinary retention. The "Risk for urinary retention r/t general anesthesia and trauma to
ureter" is early and more pressing than "Comfort, impaired r/t inability to urinate and
verbalization 'I am beginning to feel full.'"
The relationship of the medical diagnosis to the nursing diagnosis is
a. the medical diagnosis is embedded within the nursing diagnostic statement.
b. nursing diagnoses are driven by/derived from the medical diagnosis.
c. the medical diagnosis is not relevant to the nursing diagnosis.
d. the medical and nursing diagnoses should complement each other. - ANSWER the
medical and nursing diagnoses should complement each other.
Nursing diagnoses take into consideration a patient's attitudes, strengths, and
resources—not just the medical problems identified—which are critical for planning
holistic, individualized care. Medical diagnoses are not written within the nursing
diagnosis statements. Nursing diagnoses are not derived from medical diagnoses.
There is relevance of nursing diagnoses to medical diagnoses.
An example of implementation of evidenced practice by the nurse would be the nurse
a. initiates a new policy protocol for the removal of c-collars and bed board restraints of
the emergency department patient based on empirical research results.
b. watched a news report on a new procedure for chest tube removal and implements
the procedure on the patient needing chest tubes removed.
c. saw a physician perform a manipulation for vertigo related to inner ear problems and
, decides to utilize the manipulation for the current patient experiencing vertigo.
d. is assisting a physician with conscious sedation during a procedure and is asked to
perform outside the nursing scope of practice. - ANSWER initiates a new policy protocol
for the removal of c-collars and bed board restraints of the emergency department
patient based on empirical research results.
New research findings are continuously resulting in policy changes for nursing practice.
The nurse should embrace the new policy and procedures based on empirical research
results. The other options are dangerous practices for nurses, are outside their scope
of practice, and/or are not based on sound research results.
The clustering of data is significant to the nursing diagnoses step because clustering of
data will
a. show the nurse assessment is complete for this patient.
b. move the nurse toward accurate planning for the symptoms in clustered data.
c. group the data of similar problems and aid in accurate nursing diagnosis
identification.
d. organize the data for clear assessment so further assessment can occur. - ANSWER
group the data of similar problems and aid in accurate nursing diagnosis identification.
After collecting and reviewing all of the assessment data, the nurse looks for patterns
and related data to support specific nursing diagnoses. This process is referred to as
clustering data. Clustering involves organizing patient assessment data into groupings
with similar underlying causes. The nurse looks for cues among the data that support
the diagnosis of a problem. Clustering data is not associated with assessment.
Symptoms are not the only data clustered. Data are clustered during diagnosis, not
assessment.
A flat macular hemorrhage is called a(n):
a. purpura
b. ecchymosis
c. petechiae
