Test Bank Study Guide

What is the most influential factor that has shaped the nursing profession? 1) Physicians need for handmaidens 2) Societal need for healthcare outside the home 3) Military demand for nurses in the field 4) Germ theory influence on sanitation - ANSWERS3 Which of the following is an example of an illness prevention activity? Select all that apply. 1) Encouraging the use of a food diary 2) Joining a cancer support group 3) Administering immunization for HPV 4) Teaching a diabetic patient about his diet - ANSWERS3 Which of the following contributions of Florence Nightingale had an immediate impact on improving patients health? 1) Providing a clean environment 2) Improving nursing education 3) Changing the delivery of care in hospitals 4) Establishing nursing as a distinct profession - ANSWERS1 All of the following are aspects of the full-spectrum nursing role. Which one is essential for the nurse to do in order to successfully carry out all the others? 1) Thinking and reasoning about the clients care 2) Providing hands-on client care 3) Carrying out physician orders 4) Delegating to assistive personnel - ANSWERS1 Which statement pertaining to Benners practice model for clinical competence is true? 1) Progression through the stages is constant, with most nurses reaching the proficient stage. 2) Progression through the stages involves continual development of thinking and technical skills. 3) The nurse must have experience in many areas before being considered an expert. 4) The nurses progress through the stages is determined by years of experience and skills. - ANSWERS2 Which of the following best explains why it is difficult for the profession to develop a definition of nursing? 1) There are too many different and conflicting images of nurses. 2) There are constant changes in healthcare and the activities of nurses. 3) There is disagreement among the different nursing organizations. 4) There are different education pathways and levels of practice. - ANSWERS2 Nurses have the potential to be very influential in shaping healthcare policy. Which of the following factors contributes most to nurses influence? 1) Nurses are the largest health professional group. 2) Nurses have a long history of serving the public. 3) Nurses have achieved some independence from physicians in recent years. 4) Political involvement has helped refute negative images portrayed in the media. - ANSWERS1 Nursing was described as a distinct occupation in the sacred books of which faith? 1) Buddhism 2) Christianity 3) Hinduism 4) Judaism - ANSWERS3 The American Red Cross was established by 1) Louisa May Alcott 2) Clara Barton 3) Dorothea Dix 4) Harriet Tubman - ANSWERS2 Which of the following is the most important reason to develop a definition of nursing? 1) Recruit more informed people into the nursing profession 2) Evaluate the degree of role satisfaction 3) Dispel the stereotypical images of nurses and nursing 4) Differentiate nursing activities from those of other health professionals - ANSWERS4 Which of the following provides evidence-based support for the contribution that advanced practice nurses (APNs) make within healthcare? 1) Reduced usage of diagnostics using advanced technology 2) Decreased number of unnecessary visits to the emergency department 3) Improved patient compliance with prescribed treatments 4) Increased usage of complementary alternative therapies - ANSWERS3 Which of the following is an example of what traditional medicine and complementary and alternative medicine therapies have in common? 1) Both can produce adverse effects in some patients. 2) Both use prescription medications. 3) Both are usually reimbursed by insurance programs. 4) Both are regulated by the FDA. - ANSWERS1 Of the following, the biggest disadvantage of having nursing assistive personnel (NAP) help nurses is that the nurse 1) Must know what aspects of care can legally and safely be delegated to the NAP 2) May rely too heavily on information gathered by the NAP when making patient care decisions 3) Is removed from many components of direct patient care that have been delegated to the NAP 4) Still maintains responsibility for the patient care given by the NAP - ANSWERS2 An older adult has type 1 diabetes. He can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration. Which type of healthcare facility would be most appropriate for him? 1) Acute care facility 2) Ambulatory care facility 3) Extended care facility 4) Assisted living facility - ANSWERS4 The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care delivery model can you infer that this nurse is following? 1) Functional 2) Primary 3) Case method 4) Team - ANSWERS3 Which healthcare worker should the nurse consult to counsel a patient about financial and family stressors affecting healthcare? 1) Social worker 2) Occupational therapist 3) Physicians assistant 4) Technologist - ANSWERS1 Which type of managed care allows patients the greatest choice of providers, medications, and medical devices? 1) Health maintenance organization 2) Integrated delivery network 3) Preferred provider organization 4) Employment-based private insurance - ANSWERS3 A patient who underwent a total abdominal hysterectomy is assisted out of bed as soon as her vital signs are stable. This intervention is most likely being directed by a 1) Critical pathway 2) Nursing care plan 3) Case manager 4) Traditional care model - ANSWERS1 Which member of the healthcare team typically serves as the case manager? 1) Occupational therapist 2) Physician 3) Physicians assistant 4) Registered nurse - ANSWERS4 Which of the following is considered a primary care service? 1) Providing wound care 2) Administering childhood immunizations 3) Providing drug rehabilitation 4) Outpatient hernia repair - ANSWERS2 Which of the following nursing activities represent direct care? Choose all that apply. 1) Bathing a patient 2) Administering a medication 3) Documenting an assessment 4) Making work assignments for the shift - ANSWERS1 An 80-year-old patient fell and fractured her hip and is in the hospital. Before the fall, she lived at home with her husband and managed their activities of daily living very well. The goal is for the patient to recover from the injury and return to her home. The hospital is ready to discharge her because she has exceeded the recommended length of stay in a hospital. However, she cannot walk or care for herself yet, and she will require lengthy physical therapy and further monitoring of her medications and her physical and mental status. To which type of facility should she be transferred? 1) Nursing home 2) Rehabilitation center 3) Outpatient therapy center 4) None of these; she should receive home healthcare - ANSWERS2 Which of the following are examples of a health-promotion activity? Select all that apply. 1) Helping a client develop a plan for a low-fat, low-cholesterol diet 2) Disinfecting an abraded knee after a child falls off a bicycle 3) Administering a tetanus vaccination after an injury from a car accident 4) Distributing educational brochures about the benefits of exercise - ANSWERS1,4 Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking 1) Requires reasoned thought 2) Asks the questions why? or how? 3) Is a hierarchical process 4) Demands specialized thinking skills - ANSWERS1 A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to 1) Consider all the possible advantages and disadvantages 2) Maintain an open mind about the proposed change 3) Apply the nursing process to the situation 4) Make a decision based on past experience with documentation - ANSWERS2 The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step would the nurse probably do first? 1) Assessment 2) Diagnosis 3) Plan outcomes 4) Plan interventions - ANSWERS1 Which of the following is an example of theoretical knowledge? 1) A nurse uses sterile technique to catheterize a patient. 2) Room air has an oxygen concentration of 21%. 3) Glucose monitoring machines should be calibrated daily. 4) An irregular apical heart rate should be compared with the radial pulse. - ANSWERS2 Which of the following is an example of practical knowledge? (Assume all are true.) 1) The tricuspid valve is between the right atrium and ventricle of the heart. 2) The pancreas does not produce enough insulin in type 1 diabetes. 3) When assessing the abdomen, you should auscultate before palpating. 4) Research shows pain medication given intravenously acts faster than by other routes. - ANSWERS3 Which of the following is an example of self-knowledge? The nurse thinks, I know that I 1) Should take the clients apical pulse for 1 minute before giving digoxin 2) Should follow the clients wishes even though it is not what I would want 3) Have religious beliefs that may make it difficult to take care of some clients 4) Need to honor the clients request not to discuss his health concern with the family - ANSWERS3 Which of the following is the most important reason for nurses to be critical thinkers? 1) Nurses need to follow policies and procedures. 2) Nurses work with other healthcare team members. 3) Nurses care for clients who have multiple health problems. 4) Nurses have to be flexible and work variable schedules. - ANSWERS3 The nurse administering pain medication every 4 hours is an example of which aspect of patient care? 1) Assessment data 2) Nursing diagnosis 3) Patient outcome 4) Nursing intervention - ANSWERS4 How does nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is 1) Terminology for the clients disease or injury 2) A part of the clients medical diagnosis 3) The clients presenting signs and symptoms 4) A clients response to a health problem - ANSWERS4 Which statement about the nursing process is correct? 1) It was developed from the ANA Standards of Care. 2) It is a problem-solving method to guide nursing activities. 3) It is a linear process with separate, distinct steps. 4) It involves care that only the nurse will give. - ANSWERS2 What do critical thinking and the nursing process have in common? 1) They are both linear processes used to guide ones thinking. 2) They are both thinking methods used to solve a problem. 3) They both use specific steps to solve a problem. 4) They both use similar steps to solve a problem. - ANSWERS2 A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now 1) Analyze the assessment data 2) Consult standards of care 3) Decide which interventions are appropriate 4) Ask the clients perceptions of her health problem - ANSWERS1 The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patients position every 2 hours. In the evaluation phase of the nursing process, which of the following would the nurse do first? 1) Determine whether she has gathered enough assessment data. 2) Judge whether the interventions achieved the stated outcomes. 3) Follow up to verify that care for the nursing diagnosis was given. 4) Decide whether the nursing diagnosis was accurate for the patients condition. - ANSWERS2 In caring for a patient with comorbidities, the nurse draws upon her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. These activities are best described as 1) Full-spectrum nursing 2) Critical thinking 3) Nursing process 4) Nursing knowledge - ANSWERS1 The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient is obese. The nurse has been overweight at one time and works very hard now to maintain a healthy weight. She immediately thinks, I know I tend to feel negatively about obese people; I figure if I can stop eating, they should be able to. I must remember how very difficult that is and be very careful not to be judgmental of this patient. This best illustrates 1) Theoretical knowledge 2) Self-knowledge 3) Using reliable resources 4) Use of the nursing process - ANSWERS2 Which aspects of healthcare are affected by a clients culture? Select all that apply. 1) How the clients views healthcare 2) How the client views illness 3) How the client will pay for healthcare services 4) The types of treatments the client will accept 5) When the client will seek healthcare services 6) The environment where the healthcare services are provided 7) The ease of accessibility of healthcare services - ANSWERS1,2,4,5 1. Independent thinking Questioning the reason for a new staffing policy 2. Intellectual curiosity Reading the instruction manual of a new glucose monitoring machine 3. Intellectual humility Asking for help with a procedure because you have not done it before 4. Intellectual empathy Asking a patients feelings about his cancer diagnosis 5. Intellectual courage Questioning your feelings when a patients family requests withholding nutrition for a terminally ill client 6. Intellectual perseverance Obtaining the latest research about a new diagnostic procedure even though the articles are difficult to find - ANSWERS What is the role of the Joint Commission in regard to patient assessment? The Joint Commission 1) States what assessments are collected by individuals with different credentials 2) Regulates the time frames for when assessments should be completed 3) Identifies how data are to be collected and documented 4) Sets standards for what and when to assess the patient - ANSWERS4 Which of the following is an example of data that should be validated? 1) The clients weight measures 185 lb at the clinic. 2) The clients liver function test results are elevated. 3) The clients blood pressure is 160/94 mm Hg; he states that that is typical for him. 4) The client states she eats a low-sodium diet and reports eating processed food. - ANSWERS4 Which of the following examples includes both objective and subjective data? 1) The clients blood pressure is 132/68 and her heart rate is 88. 2) The clients cholesterol is elevated, and he states he likes fried food. 3) The client states she has trouble sleeping and that she drinks coffee in the evening. 4) The client states he gets frequent headaches and that he takes aspirin for the pain. - ANSWERS2 The Joint Commission requires which type of assessment to be performed on all patients? 1) Functional ability 2) Pain 3) Cultural 4) Wellness - ANSWERS2 Which of the following is an example of an ongoing assessment? 1) Taking the patients temperature 1 hour after giving acetaminophen (Tylenol) 2) Examining the patients mouth at the time she complains of a sore throat 3) Requesting the patient to rate intensity on a pain scale with the first perception of pain 4) Asking the patient in detail how he will return to his normal exercise activities - ANSWERS1 When should the nurse make systematic observations about a patient? 1) When the patient has specific complaints 2) With the first assessment of the shift 3) Each time the nurse gives medications to the patient 4) Each time the nurse interacts with the patient - ANSWERS4 Which of the following is an example of an open-ended question? 1) Have you had surgery before? 2) When was your last menstrual period? 3) What happens when you have a headache? 4) Do you have a family history of heart disease? - ANSWERS3 Of the following recommended interviewing techniques, which one is the most basic? (That is, without that intervention, the others will all be less effective.) 1) Beginning with neutral topics 2) Individualizing your approach 3) Minimizing note taking 4) Using active listening - ANSWERS4 Which of the following is an example of the most basic motivation in Maslows hierarchy of needs? 1) Experiencing loving relationships 2) Having adequate housing 3) Receiving education 4) Living in a crime-free neighborhood - ANSWERS2 What makes a nursing history different from a medical history? 1) A nursing history focuses on the patients responses to the health problem. 2) The same information is gathered; the difference is in who obtains the information. 3) A nursing history is gathered using a specific format. 4) A medical history collects more in-depth information. - ANSWERS1 Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies? 1) To determine what type of therapies are acceptable to the client 2) To identify whether the client has a nutrition deficiency 3) To help you to understand cultural and spiritual beliefs 4) To identify potential interaction with prescribed medication and therapies - ANSWERS4 What do the nursing assessment models have in common? 1) They assess and cluster data into model categories. 2) They organize assessment data according to body systems. 3) They specify use of the nursing process to collect data. 4) They are based on the ANA Standards of Care. - ANSWERS1 Nondirective interviewing is a useful technique because it 1) Allows the nurse to have control of the interview 2) Is an efficient way to interview a patient 3) Facilitates open communication 4) Helps focus patients who are anxious - ANSWERS3 A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate the need for further instruction? 1) My patient is a young adult, so I plan to talk to her without her parents in the room. 2) Because my patient is old enough to be my grandfather, I will call him Mr. 3) When reading my patients health record, I thought of a few questions to ask. 4) When I give my patient his pain medication, I will have time to ask questions. - ANSWERS4 A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform? 1) Comprehensive 2) Ongoing 3) Initial focused 4) Special needs - ANSWERS3 A patient has left-sided weakness because of a recent stroke. Which type of special needs assessment would it be most important to perform? 1) Family 2) Functional 3) Community 4) Psychosocial - ANSWERS2 The nurse is interviewing a patient who has a recent onset of migraine headaches. The patient is highly anxious and cannot seem to focus on what the nurse is saying. Which of the following questions would be best for the nurse to use to begin gathering data about the headaches? 1) When did your migraines begin? 2) Tell me about your family history of migraines. 3) What are the types of things that trigger your headaches? 4) Describe what your headaches feel like. - ANSWERS1 Which of the following is an example of an active listening behavior? 1) Taking frequent notes 2) Asking for more details 3) Leaning toward the patient 4) Sitting with legs crossed - ANSWERS3 A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching? 1) I find it difficult to avoid using phrases like, The patient tolerated the procedure well. 2) Its confusing to have to remember which abbreviations this hospital allows. 3) I need to work on charting assessments and interventions right after they are done. 4) My patient was really quiet and didnt say much, so I charted that he acted depressed. - ANSWERS4 For which of the following purposes is a graphic flow sheet superior to other methods of recording data? 1) Easy documentation of routine vital signs 2) Seeing the patterns of a patients fever 3) Describing the symptoms accompanying a rising temperature 4) Checking to make sure vital signs were taken - ANSWERS2 The most obvious reason for using a framework when assessing a patient is to 1) Prioritize assessment data 2) Organize and cluster data 3) Separate subjective and objective data 4) Identify primary from secondary data - ANSWERS2 Which situation is the most conducive to conducting a successful interview of an elderly woman whose husband and two children are in the hospital room visiting and watching television? The woman is alert and oriented. 1) Provide enough chairs so the family and you are able to sit facing the client. 2) Introduce yourself and ask, Dear, what name do you prefer to go by? before asking any questions. 3) After the family leaves, ask the client if she is comfortable and willing to answer a few questions. 4) Ask the client if you can talk with her while her family is watching the television. - ANSWERS3 Which of the following questions would be effective for obtaining information from a patient? Choose all that apply. 1) How did this happen to you? 2) What was your first symptom? 3) Why didnt you seek healthcare earlier? 4) When did you start having symptoms? - ANSWERS1,2,4 A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) or a registered nurse (RN). To which sources should the nurse turn for the answer to his question? Choose all that are appropriate. 1) The nurse practice act of his state 2) The American Medical Association guidelines 3) The Code of Ethics for Nurses 4) The American Nurses Associations Scope and Standards of Practice - ANSWERS1,4 Which of the following are cues rather than inferences? Choose all correct answers. 1) Ate 50% of his meal 2) Patient feels better today 3) States, I slept well 4) White blood cell count 15,000/mm3 - ANSWERS1,3,4 Which of the following is an example of a problem that nurses can treat independently? 1) Hemorrhage 2) Nausea 3) Fracture 4) Infection - ANSWERS2 Which of the following is an example of a cluster of related cues? 1) Complains of nausea and stomach pain after eating 2) Has a productive cough and states stools are loose 3) Has a daily bowel movement and eats a high-fiber diet 4) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84 - ANSWERS1 Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology 1) Is the cause of the problem 2) Cannot always be observed 3) Directs nursing care 4) Is an inference - ANSWERS3 How does a risk nursing diagnosis differ from a possible nursing diagnosis? 1) A risk diagnosis is based on data about the patient. 2) A possible diagnosis is based on partial (or incomplete) data. 3) Nurses collect the data to support risk diagnoses. 4) A possible diagnosis becomes an actual diagnosis when symptoms develop. - ANSWERS2 Which of the following describes the difference between a collaborative problem and a medical diagnosis? 1) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. 2) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. 3) A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes. 4) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician. - ANSWERS4 Which of the following is the best approach to validate a clinical inference? 1) Have another nurse evaluate it. 2) Have the physician evaluate it. 3) Have sufficient supportive data. 4) Have the clients family confirm it. - ANSWERS3 What is wrong with the following diagnostic statement? Impaired Physical Mobility related to laziness and not having appropriate shoes. The statement is 1) Judgmental 2) Too complex 3) Legally questionable 4) Without supportive data - ANSWERS1 When making a diagnosis using NANDA-I, which of the following provides support for the diagnostic label you choose? 1) Etiology 2) Related factors 3) Diagnostic label 4) Defining characteristics - ANSWERS4 Based only on Maslows hierarchy of needs, which nursing diagnosis should have the highest priority? 1) Self-care Deficit 2) Risk for Aspiration 3) Impaired Physical Mobility 4) Disturbed Sensory Perception - ANSWERS2 Which of the following describes the most important use of nursing diagnosis? (All statements are true.) 1) Differentiates the nurses role from that of the physician 2) Identifies a body of knowledge unique to nursing 3) Helps nursing develop a more professional image 4) Describes the clients needs for nursing care - ANSWERS4 Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I? 1) There is little research to support nursing diagnoses labels. 2) A perfect nursing diagnosis must be written for it to be useful. 3) They are not included in all states nurse practice acts. 4) Other professions do not recognize nursing diagnoses. - ANSWERS1 Which of the following most accurately describes nursing diagnoses? A nursing diagnosis 1) Supports the nurses diagnostic reasoning 2) Supports the clients medical diagnosis 3) Identifies a clients response to a health problem 4) Identifies a clients health problem - ANSWERS3 The diagnostic label, or patient problem, is used primarily to suggest 1) Client goals 2) Cue clusters 3) Interventions 4) Etiology - ANSWERS1 Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy? 1) Bowel Obstruction related to recent abdominal surgery A.M.B. nausea, vomiting, and abdominal pain 2) Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight 3) Impaired Skin Integrity related to physical immobility A.M.B. skin tear over sacral area 4) Caregiver Role Strain related to alienation from family and friends A.M.B 24-hour care responsibilities - ANSWERS3 What is wrong with the format of this diagnostic statement: Possible Risk for Constipation related to irregular defecation habits A.M.B. statement that When Im busy, I cant always take the time to go to the bathroom. 1) Possible nursing diagnoses do not have signs and symptoms. 2) A nursing diagnosis is either a possible risk or a risk, not both. 3) Constipation is a medical diagnosis. 4) The etiology is actually a defining characteristic. - ANSWERS2 Which nursing diagnosis is written in the correct format? 1) Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight 2) Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm 3) Impaired Swallowing related to absent gag reflex 4) Excess Fluid Volume related to 3 lb weight gain in 24 hours - ANSWERS3 The patient shows the necessary defining characteristics, and the nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs. What essential action should the nurse take to help ensure the accuracy of this diagnosis? 1) Ask a more experienced nurse to confirm it. 2) Have a social worker interview the patient. 3) Ask the patient to confirm the diagnosis. 4) Read about Decisional Conflict in the NANDA-I handbook. - ANSWERS3 The clients weight is appropriate for his height. His laboratory values and other assessments reflect normal nutritional status. However, he has told the nurse, I probably eat a little too much red meat. And what is this I hear about needing omega 3 oils in my diet? I dont like to take supplements, and I think I could really improve my nutrition. Which of the following nursing diagnoses should the nurse use? 1) Balanced Nutrition 2) Possible Imbalanced Nutrition: Less Than Body Requirements 3) Risk for Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition - ANSWERS4 The patient verbalizes an overwhelming lack of energy. He says, I still feel exhausted even after I sleep. I feel guilty when I cant keep up with my usual daily activities or sleep during the day. Ive been a little depressed lately, too. The patient seems to have difficulty concentrating but has no apparent physical problems. Which of the following diagnoses best describes his health status? 1) Fatigue related to depression 2) Fatigue related to difficulty concentrating 3) Guilt related to lack of energy 4) Chronic confusion related to lack of energy - ANSWERS1 Which of the following nursing diagnoses is written in correct format? Assume the facts are correct in all of them. 1) Readiness for Enhanced Nutrition 2) Pain related to stating, On a scale of 1 to 5, its a 5. 3) Impaired Mobility related to pain A.M.B. hip fracture 4) Risk for Infection related to compromised immunity A.M.B. fever - ANSWERS1 Which of the following are cues? Select all that apply. 1) Taking a brisk walk five times a week 2) Using laxatives to have a bowel movement 3) Needing more sleep than usual 4) Decreasing the amount of fat in the diet 5) Weighing less than indicated by developmental norms - ANSWERS2,3,5 Using Maslows hierarchy of needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. 1) Anxiety 2) Risk for infection 3) Disturbed body image 4) Sleep deprivation - ANSWERS4,2,1,3 For which patient would it be most important to perform a comprehensive discharge plan? 1) A teen who is a first-time mother, single, and lives with her parents 2) An older adult who has had a stroke affecting the left side of his body and lives alone 3) A middle-aged man who has had outpatient surgery on his knee and requires crutches 4) A young woman who was admitted to the hospital for observation following an accident - ANSWERS2 The nurse is beginning discharge planning for an older adult with left-side weakness. All of the following are important, but which action is most important in ensuring that the discharge plan is successful? 1) Start planning at admission. 2) Involve the family members. 3) Get patient input when making the plan. 4) Involve the multidisciplinary team. - ANSWERS3 What do initial, ongoing, and discharge planning have in common? 1) They are based on assessment and diagnosis. 2) They focus on the patients perception of his needs. 3) They require input from a multidisciplinary team. 4) They have specific timelines in which to be completed. - ANSWERS1 Which client has the greatest need for comprehensive discharge planning? 1) A woman who has just given birth to her second child and lives with her husband and 18-month-old daughter 2) 3) A 12-year-old boy who had outpatient surgery on his knee and lives with his mother 4) A man who has been readmitted for exacerbation of his chronic obstructive pulmonary disease A woman who was just diagnosed with renal failure and has started peritoneal dialysis - ANSWERS4