GNUR 238 EXAM #2 QUESTIONS AND ANSWERS
Answer: C --> The nursing process is the methodology used to "think like a nurse."
Providing patient-centered care (a) and enhancing communication among health team
members (d) is facilitated through the use of care plans.
Collaborating with rather than identifying members of the health care team (b) is part of
many plans of care. - Answers - What is the purpose of the nursing process?
a. Providing patient-centered care
b. Identifying members of the health care team
c. Organizing the ways nurses think about patient care
d. Facilitating communication among members of the health care team
Answer: D
In an emergent situation, the nurse initially focuses on the patient's chief complaint to
determine its cause. Before initiating care, the nurse gathers information on the other
topics. - Answers - A patient comes to the emergency department complaining of
nausea and vomiting. What should the nurse ask the patient about first?
a. Family history of diabetes
b. Medications the patient is taking
c. Operations the patient has had in the past
d. Severity and duration of the nausea and vomiting
Answer: D
Nursing diagnoses emerge from groupings of clustered data collected during the
assessment phase of the nursing process.
Choices A, B, and D are all part of the clustered data used to make a nursing diagnosis.
- Answers - On what premise is a nursing diagnosis identified for a patient?
a. First impressions
b. Nursing intuition
c. Clustered data
d. Medical diagnoses
Answer: A
Goals are to be patient-focused, realistic, and measurable. Only the first goal meets
these three criteria. - Answers - Which statement is an appropriately written short-term
goal?
,a. Patient will walk to the bathroom independently without falling within 2 days after
surgery.
b. Nurse will watch patient demonstrate proper insulin injection technique each morning.
c. Patient's spouse will express satisfaction with patient's progress before discharge.
d. Patient's incision will be well approximated each time it is assessed by the nurse.
Answer: A --> Patient needs are always the primary focus of nursing interventions.
Nursing concerns, physician priorities, and family requests can provide additional
guidance in the development of a patient-centered plan of care. - Answers - What
should be the primary focus for nursing interventions?
a. Patient needs
b. Nurse concerns
c. Physician priorities
d. Patient's family requests
Answer: C --> Knowing the scope of practice of the other team member is critical to
understanding what is appropriate and safe to delegate to that person.
It is unnecessary to locate or meet with all members of the health care team prior to
delegation. Physicians are already aware of potential complications related to patient
care. - Answers - Which nursing action is critical before delegating interventions to
another member of the health care team?
a. Locate all members of the health care team.
b. Notify the physician of potential complications.
c. Know the scope of practice for the other team member.
d. Call a meeting of the health care team to determine the needs of the patient.
Answer: A
When a patient shares a concern, the first action by the nurse is to assess potential
reasons for the patient's problem. Depending on the underlying reason for the patient's
inability to sleep, the nurse may then want to administer prescribed sleep medication,
teach the patient some relaxation techniques, or discuss patient behaviors with the
primary care provider. - Answers - A patient reports feeling tired and complains of not
sleeping at night. What action should the nurse perform first?
a. Identify reasons the patient is unable to sleep.
b. Request medication to help the patient sleep.
c. Tell the patient that sleep will come with relaxation.
d. Notify the physician that the patient is restless and anxious.
,Answer: C --> The nurse should evaluate the need to continue or discontinue a plan of
care if a patient has met a short-term goal.
The nurse collects primary data directly from patients who are alert and oriented.
Family members and other members of the health care team may provide secondary
data on patients. - Answers - An alert and oriented patient is admitted to the hospital
with chest pain. Who is the best source of primary data on this patient?
a. Family member
b. Physician
c. Another nurse
d. Patient
Answer: B
Each nursing diagnosis label identifies either a patient problem or need, which is its
purpose.
Resolving patient confusion, meeting accreditation requirements, and articulating the
nurse's scope of practice are not related to the purpose of the nursing diagnostic
process. - Answers - What is the primary purpose of the nursing diagnosis?
a. Resolving patient confusion
b. Communicating patient needs
c. Meeting accreditation requirements
d. Articulating the nursing scope of practice
Answer: C
Wrong answers:
A) It is unnecessary to consult the surgeon unless there is a concern.
B) Discontinuing the care plan may be premature, and the decision needs to be
evaluated before taking action. The patient's intake and output will continue to be
monitored throughout hospitalization, not just for 1 hour after surgery.
D) Other interventions may still require implementation and other goals may not yet
have been met - Answers - What action should the nurse take regarding a patient's plan
of care if the patient appears to have met the short-term goal of urinating within 1 hour
after surgery?
a. Consult the surgeon to see if the clinical pathway is being followed.
b. Discontinue the plan of care, because the patient has met the established goal.
c. Monitor patient urine output to evaluate the need for the current plan of care.
d. Notify the patient that the goal has been attained and no further intervention is
needed.
, Critical Thinking - Answers - Involves the application of knowledge and experience to
identify patient problems and to direct clinical judgments and actions that result in
positive patient outcomes. It is influenced by scientific research and best practice. In
nursing, ___________ is used synonymously with problem solving, decision making,
reasoning, and judgment.
Critical Reasoning - Answers - Uses critical thinking, knowledge, and experience to
develop solutions to problems and make decisions in a clinical setting. These skills
develop over time and increase with knowledge and experience.
Reflection - Answers - Deliberate thinking about something that has occurred or
happened. Done during practice to improve future caregiving.
Evidence - Answers - Identification of science and research that ensures nursing
practice is within standards of care
Standards - Answers - Established by the American Nurse's Association (ANA) based in
areas like ethics, research, leadership, and collaboration. Determining what is the most
current evidence based practice.
1. Their role
2. Their scope of practice
3. The competency of the person - Answers - What must a nurse know about the
recipient of a delegated task?
Routine and aimless thinking
This type of thinking is not purposeful in nature. - Answers - The following is an example
of ________ thinking:
A nursing assistant is assigned to give personal care to a client who had a colon
resection yesterday. She is thinking, "I need to get this bath done because I've got four
more to do before lunch."
Left brain thinking - Answers - The side of the brain that is believed to be responsible for
logical and linear type of thinking. Involved in problem solving. "Math types" with
absolute answers.
Right brain thinking - Answers - The side of the brain that is believed to be responsible
for creative and multidirectional thinking. Can look at the whole picture and likes to
prevent problems before they even happen.
ADPIE:
1. Assessment
2. Diagnosis (nursing diagnoses only!)
Answer: C --> The nursing process is the methodology used to "think like a nurse."
Providing patient-centered care (a) and enhancing communication among health team
members (d) is facilitated through the use of care plans.
Collaborating with rather than identifying members of the health care team (b) is part of
many plans of care. - Answers - What is the purpose of the nursing process?
a. Providing patient-centered care
b. Identifying members of the health care team
c. Organizing the ways nurses think about patient care
d. Facilitating communication among members of the health care team
Answer: D
In an emergent situation, the nurse initially focuses on the patient's chief complaint to
determine its cause. Before initiating care, the nurse gathers information on the other
topics. - Answers - A patient comes to the emergency department complaining of
nausea and vomiting. What should the nurse ask the patient about first?
a. Family history of diabetes
b. Medications the patient is taking
c. Operations the patient has had in the past
d. Severity and duration of the nausea and vomiting
Answer: D
Nursing diagnoses emerge from groupings of clustered data collected during the
assessment phase of the nursing process.
Choices A, B, and D are all part of the clustered data used to make a nursing diagnosis.
- Answers - On what premise is a nursing diagnosis identified for a patient?
a. First impressions
b. Nursing intuition
c. Clustered data
d. Medical diagnoses
Answer: A
Goals are to be patient-focused, realistic, and measurable. Only the first goal meets
these three criteria. - Answers - Which statement is an appropriately written short-term
goal?
,a. Patient will walk to the bathroom independently without falling within 2 days after
surgery.
b. Nurse will watch patient demonstrate proper insulin injection technique each morning.
c. Patient's spouse will express satisfaction with patient's progress before discharge.
d. Patient's incision will be well approximated each time it is assessed by the nurse.
Answer: A --> Patient needs are always the primary focus of nursing interventions.
Nursing concerns, physician priorities, and family requests can provide additional
guidance in the development of a patient-centered plan of care. - Answers - What
should be the primary focus for nursing interventions?
a. Patient needs
b. Nurse concerns
c. Physician priorities
d. Patient's family requests
Answer: C --> Knowing the scope of practice of the other team member is critical to
understanding what is appropriate and safe to delegate to that person.
It is unnecessary to locate or meet with all members of the health care team prior to
delegation. Physicians are already aware of potential complications related to patient
care. - Answers - Which nursing action is critical before delegating interventions to
another member of the health care team?
a. Locate all members of the health care team.
b. Notify the physician of potential complications.
c. Know the scope of practice for the other team member.
d. Call a meeting of the health care team to determine the needs of the patient.
Answer: A
When a patient shares a concern, the first action by the nurse is to assess potential
reasons for the patient's problem. Depending on the underlying reason for the patient's
inability to sleep, the nurse may then want to administer prescribed sleep medication,
teach the patient some relaxation techniques, or discuss patient behaviors with the
primary care provider. - Answers - A patient reports feeling tired and complains of not
sleeping at night. What action should the nurse perform first?
a. Identify reasons the patient is unable to sleep.
b. Request medication to help the patient sleep.
c. Tell the patient that sleep will come with relaxation.
d. Notify the physician that the patient is restless and anxious.
,Answer: C --> The nurse should evaluate the need to continue or discontinue a plan of
care if a patient has met a short-term goal.
The nurse collects primary data directly from patients who are alert and oriented.
Family members and other members of the health care team may provide secondary
data on patients. - Answers - An alert and oriented patient is admitted to the hospital
with chest pain. Who is the best source of primary data on this patient?
a. Family member
b. Physician
c. Another nurse
d. Patient
Answer: B
Each nursing diagnosis label identifies either a patient problem or need, which is its
purpose.
Resolving patient confusion, meeting accreditation requirements, and articulating the
nurse's scope of practice are not related to the purpose of the nursing diagnostic
process. - Answers - What is the primary purpose of the nursing diagnosis?
a. Resolving patient confusion
b. Communicating patient needs
c. Meeting accreditation requirements
d. Articulating the nursing scope of practice
Answer: C
Wrong answers:
A) It is unnecessary to consult the surgeon unless there is a concern.
B) Discontinuing the care plan may be premature, and the decision needs to be
evaluated before taking action. The patient's intake and output will continue to be
monitored throughout hospitalization, not just for 1 hour after surgery.
D) Other interventions may still require implementation and other goals may not yet
have been met - Answers - What action should the nurse take regarding a patient's plan
of care if the patient appears to have met the short-term goal of urinating within 1 hour
after surgery?
a. Consult the surgeon to see if the clinical pathway is being followed.
b. Discontinue the plan of care, because the patient has met the established goal.
c. Monitor patient urine output to evaluate the need for the current plan of care.
d. Notify the patient that the goal has been attained and no further intervention is
needed.
, Critical Thinking - Answers - Involves the application of knowledge and experience to
identify patient problems and to direct clinical judgments and actions that result in
positive patient outcomes. It is influenced by scientific research and best practice. In
nursing, ___________ is used synonymously with problem solving, decision making,
reasoning, and judgment.
Critical Reasoning - Answers - Uses critical thinking, knowledge, and experience to
develop solutions to problems and make decisions in a clinical setting. These skills
develop over time and increase with knowledge and experience.
Reflection - Answers - Deliberate thinking about something that has occurred or
happened. Done during practice to improve future caregiving.
Evidence - Answers - Identification of science and research that ensures nursing
practice is within standards of care
Standards - Answers - Established by the American Nurse's Association (ANA) based in
areas like ethics, research, leadership, and collaboration. Determining what is the most
current evidence based practice.
1. Their role
2. Their scope of practice
3. The competency of the person - Answers - What must a nurse know about the
recipient of a delegated task?
Routine and aimless thinking
This type of thinking is not purposeful in nature. - Answers - The following is an example
of ________ thinking:
A nursing assistant is assigned to give personal care to a client who had a colon
resection yesterday. She is thinking, "I need to get this bath done because I've got four
more to do before lunch."
Left brain thinking - Answers - The side of the brain that is believed to be responsible for
logical and linear type of thinking. Involved in problem solving. "Math types" with
absolute answers.
Right brain thinking - Answers - The side of the brain that is believed to be responsible
for creative and multidirectional thinking. Can look at the whole picture and likes to
prevent problems before they even happen.
ADPIE:
1. Assessment
2. Diagnosis (nursing diagnoses only!)
