NSG 303 EXAM STUDY PACK WITH FULL QUESTION SET, EXPLAINED ANSWERS, AND SOLVED SOLUTIONS

1. What are some examples of psychomotor goals? - ANSWER -by 3/30/20, the patient will successfully navigate the length of the hallway with a walker -by 3/30/20, the patient will bathe infant on her own 2. What are some examples of affective goals? - ANSWER -by 3/30/20, the patient will value her health sufficiently to stop smoking -by 3/30/20, the patient will show concern for his well-being and participate in AA meetings 3. Initial planning - ANSWER -addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care -Standardized care plans provide an excellent basis for this type of planning if the nurse individualizes them 4. Ongoing planning - ANSWER -Used to keep the nursing care plan up to date -States nursing diagnoses more clearly and develops new diagnoses 5. Discharge planning - ANSWER -Should be carried out by the nurse who has worked most closely with the patient and family -Involves teaching and counseling skills to help the patient and family carry out self-care behaviors at home 6. What are two examples of informal planning? - ANSWER -A postpartum nurse learns that a patient is complaining of soreness r/t unsuccessful attempts to breastfeed her infant and plans to spend more time with her -A home health care nurse quickly assesses safety in the home of a patient prone to accidents 7. How does a formal plan of care benefit the nurse and the patient? - ANSWER It allows the nurse to individualize care; set priorities; facilitate communication among nursing personnel; promote continuity of care; coordinate care; evaluation the patient's response to nursing care; and promote the nurse's professional development 8. What are four considerations a nurse should employ when planning nursing care for each day? - ANSWER -have changes in the patient's health status influenced the priority of nursing diagnoses? -have changes in the way the patient is responding the health and illness or the care plan affected those nursing diagnoses that can be realistically addressed? -Are there relationships among diagnoses that require that one be worked on before another can be resolved? -Can several patient problems be dealt with together? 9. What are 6 measures nurses should consider to correctly plan health care for a patient? - ANSWER 1. Be familiar with standards and facility policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence based nursing interventions, and recording the care plan 2. Remember that the goal of patient-centered care is to keep the patient and the patient's interests and preferences central in every aspect of planning 3. Keep the "big picture" in focus. What are the discharge goals for this patient, and how should this direct each shift's interventions? 4. Trust clinical experience and judgement but be willing to ask for help when the situation demands more than your qualifications and experience can provide; value collaborative practice 5. Respect your clinical institution, but before establishing priorities, identifying outcomes, and selecting nursing interventions, be sure that research supports your plan 6. Recognize personal biases and keep an open mind 10. What are 4 examples of questions a nurse should ask when thinking critically about setting priorities for a patient plan of care? - ANSWER 1. What problems need immediate attention, and what could happen if I wait to attend to them? 2. Which problems are my responsibility, and which do I need to refer to someone else? 3. Which problems can be dealt with by using standard plans (e.g., critical paths, standards of care)? 4. Which problems are not covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge? 11. A nurse is planning care for a patient who has just been diagnosed with type 2 diabetes. What nursing action is performed during the planning step of the nursing process? - ANSWER The nurse selects nursing measures, including patient teaching 12. A nurse is writing goals for a patient who is scheduled to ambulate following hip replacement surgery. What is an example of a goal for this patient? - ANSWER Over the next 24 hour period, the patient will walk the length of the hallway assisted by a nurse 13. The nurse is caring for a 48-year-old male patient with a new colostomy. What is an examples of a patient goal? - ANSWER The patient will demonstrate proper care of stoma by 3/30/20 14. When planning nursing interventions, the nurse must review the etiology of the problem statement. What does the etiology do? - ANSWER Identifies factors causing undesirable response and preventing desired change 15. A nurse is caring for an overweight, highly stressed 50-year-old male executive who is being discharged from the hospital after undergoing coronary bypass surgery. What is an affective goal for this patient? - ANSWER By 6/30/20, the patient will value his health sufficiently to reduce the cholesterol in his diet 16. A nurse is planning nursing interventions for patients on a busy hospital ward. What guideline would the nurse follow when designing the care plan? - ANSWER Date the nursing interventions when written and when the care of plan is reviewed 17. The nurse is aware that basic patient needs must be met before a patient can focus on higher ones. According to Maslow's hierarchy of needs, what would be an example of the highest priority for a patient after physiological needs have been met? - ANSWER Grab bars are installed in a patient's bathroom to facilitate safe showering 18. A nurse is planning care for patients in a health care provider's office. What are examples of actions the nurse will perform during this step of the nursing process? - ANSWER -Establishing priorities -Identifying expected patient outcomes -Communicating the nursing care plan 19. A nurse is performing initial care planning for a hospitalized patient. What are some actions that occur during the initial planning of patient care? - ANSWER -The nurse who performs the admission nursing history and physical assessment makes the initial plan -The nurse identifies patient goals and the related nursing care in the initial goal 20. A nurse is writing outcomes for patients in a rehabilitation facility. What are come guidelines a nurse should consider? - ANSWER -At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis -The nurse should write outcomes that are brief and specific and support the overall plan of care 21. The nurse is writing goals for patients being discharged from an acute care setting. What are examples of goals for these patients? - ANSWER -After attending an infant care class, the patient will correctly demonstrate the procedure for bathing her newborn -by 4/5/20, the patient will demonstrate how to care for her colostomy -After counseling, the patient will describe two coping measures to deal with stress 22. What does the acronym SMART stand for? - ANSWER Specific, Measurable, Attainable, Realistic, Timely 23. When a nurse administers medication that were prescribed by the patient's doctor, what health intervention is he/she carrying out? - ANSWER Health care provider-initiated 24. What are written plans that detail the nursing activities to be executed in specific situations, such as might occur in the ED of the hospital? - ANSWER protocols 25. What type of interventions are targeted to promote and preserve the health of populations? - ANSWER Community (or public health) interventions 26. What type of intervention is a treatment performed away from the patient but on behalf of the patient of group of patients? - ANSWER Indirect care 27. McCloskey and Bulechek published a report of research to construct a taxonomy of nursing interventions known as _______________ - ANSWER Nursing Interventions Classifications (NIC) 28. Interventions that are performed jointly by nurses and other members of the health care team are know as what? - ANSWER Collaborative interventions 29. What are examples of nurse-initiated independent interventions? - ANSWER -A nurse notices that her patient is extremely anxious before surgery and recommends psychiatric evaluation by the psychiatric nurse specialist -A nurse teaches a daughter of a patient who has leg ulcers how to apply the dressing 30. What are examples of health care provider-initiated dependent interventions? - ANSWER -A nurse administers the prescribed dosage of pain medication for a patient recovering from knee surgery -A nurse prepares a patient for surgery by performing a bowel cleansing 31. What are examples of Collaborative interdependent interventions? - ANSWER -A nurse meets with a patient's health care provider to describe the patient's lack of response to prescribed therapy -A nurse meets in conference with a patient's health care provider, social worker, and psychiatrist to discuss the patient's failure to progress 32. Who is legally responsible for the assessments nurses make and for their nursing responses? - ANSWER The nurse 33. What type of intervention involve carrying out nurse-prescribed orders written on the nursing plan? - ANSWER Nursing-initiated interventions 34. Who plays the role of the coordinator within the health care team? - ANSWER the nurse 35. Who carries out the nursing orders detailed in the nursing care plan? - ANSWER the nursing team 36. When working with patients to achieve the goals/outcomes specified in the care plan, what is important to remember? - ANSWER Nothing about the care plan is fixed 37. When choosing nursing interventions, what is important to consider? - ANSWER the patient's background 38. Sincere motivation to benefit the patient and conscientious attempt to implement nursing orders are _____________ to protect a nurse from legal action due to negligence - ANSWER not sufficient 39. When a patient fails to follow the care plan despite the nurses best efforts, what should the nurse do? - ANSWER Reassess the strategy 40. If a care plan is well written, what is the nurse's most important test and top priority? - ANSWER carrying out the care plan's orders 41. What are 3 duties nurses perform when acting as coordinators for the health care team? - ANSWER 1. Interpret the specialist's findings for patients and family members 2. Prepare patients to participate maximally in the care plan before and after discharge 3. Serve as a liaison among the members of the health care team 42. What is an example of a nurse variable? - ANSWER A nurse with overwhelming outside concerns 43. What is an example of a patient variable? - ANSWER A patient who gives up 44. What is an example of a health care variable? - ANSWER Understaffing causes over-worked nurses 45. The Joint Commission encourages patients to become active, involved, and informed participants on the health care team. What nursing action follows the Joint Commission recommendations for improving patient safety by encouraging patients to speak up? - ANSWER The nurse encourages the patient the participate in all treatment decisions as the center of the health care team 46. Nurses perform many independent nursing actions when caring for patients. Which action is considered an independent (nurse-initiated) action? - ANSWER Helping to allay a patient's fears about surgery 47. A nurse follows set guidelines for administering pain medication to patients in critical care unit. The nurse's authority to initiate actions the normally require the order or supervision of a health care provider is termed: - ANSWER Standing orders 48. As the nurse bathes a patient, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important? - ANSWER It enables the nurse to revise the care plan appropriately 49. A patient, who presented with high blood pressure, is put on a low sodium diet and instructed to quit smoking. The nurse finds him in the cafeteria eating a cheeseburger and French fries. He also tells you there is no way he can quit smoking. What is the nurse's first objective when implementing care for this patient? - ANSWER Identify why the patient is not following the therapy 50. Nurses implement care for patients in carious health care settings. What are some activities would typically be carried out during the implementation step of the nursing process? - ANSWER -Collecting additional patient data -Modifying the patient care plan 51. Nurses use the Nursing Outcomes Classifications (NOCs) when choosing nursing goals for patients. What are goals of the research that is behind the NOCs? - ANSWER -To identify, label, and validate nursing-sensitive patient outcomes and indicators -To evaluate the validity and usefulness of the classification in clinical field testing -To define and test measurement procedures for the outcomes and indicators 52. Nurses utilize the McCloskey, Dochterman, and Bulechek Nursing Interventions Classifications (NIC) report of research when choosing nursing interventions for patients. What are some advantages of having standard NICs? - ANSWER -Teaching decision making -Allocating nursing resources -Developing information systems -Communicating nursing to non-nurses 53. What are some examples of nursing actions listed in the ANA's Nursing: Scope and Standards of Practice for Standard 5: Implementation? - ANSWER -The nurse documents implementation and any modifications, including changes and omissions, of the identified plan -The nurse uses evidence-based interventions and strategies to achieve the mutually identified goals and outcomes specific to the problem needs -The nurse integrates critical thinking and technology solutions to implement the nursing process to collect, measure, record, retrieve, trend, and analyze data and information to enhance nursing practice and heath care consumer outcomes 54. During the evaluation step of the nursing process, based on the patient's responses to the care plan, what are three things the nurse decides to do with the care plan? - ANSWER 1. terminate the care plan 2. modify the care plan 3. continue the care plan 55. Nurses are involved in many types of evaluations. What is always the nurse's primary concern? - ANSWER the patient 56. The most important act of evaluation performed by nurses is to evaluate what? - ANSWER outcome achievement with the patient 57. The nurse evaluates a patient's outcome by measuring the skills and knowledge that the patient has achieved. These measurable qualities, attributes, or characteristics are called: - ANSWER criteria 58. What are levels of performance accepted by and expected of the nursing staff or other health care team members established by authority, custom, or consent? - ANSWER Standards 59. What are recommendations for how care should be managed in specific diseases, problems, or situations? - ANSWER Clinical practice guidelines 60. The nurse manage of a hospital unit sets up a program to help improve teamwork on the unit. These types of specially designed programs that promote excellence in nursing are called: - ANSWER quality assurance programs 61. An inspector is evaluating the physical facility and equipment of a health care provider's office. This type of evaluation that focuses on the environment in which care is provided is called: - ANSWER a structure evalution 62. A person who evaluates nursing care by using post-discharge questionnaires, patient interviews (by phone or face-to-face), or chart review (nursing audit) to collect data is conducting what type of evaluation? - ANSWER Retrospective 63. What is an evaluation that focuses on the environment in which care is provided? - ANSWER structure evaluation 64. What type of evaluation focuses on measurable changes in the health status of a patient? - ANSWER outcome evaluation 65. What type of evaluation of nursing care and patient goals is used while the patient is receiving the care? - ANSWER concurrent evaluation 66. What type of evaluation focuses on the nature and sequence of activities carried out by the nurse implementing the nursing process? - ANSWER process evaluation 67. What type of evaluation is used to collect data after discharge usually by using post-discharge interviews and questionnaires and chart review? - ANSWER Retrospective evaluation 68. What are examples of a criteria measurement tool? - ANSWER patient will be able to walk the length of the hall by 5/5/20 -Upon completion of an ECG course, the nurse will be able to recognize common arrhythmias when they appear on a heart monitor -The student will be able to name and describe steps of the nursing procedure by the end of the semester 69. What are examples of standard measurement tools? - ANSWER The admission database will be completed al all patients within 24 hours of admission to the unit -All patients in active labor will have continuous external fetal heart monitoring 70. What are examples of patient, nurse, and health care system variables the may influence goal/outcome achievement? - ANSWER 1. Patient: is the pt motivated to learn new health behavior: 2. Nurse: do the nurses come to work well rested and ready to help their patients? 3. Health Care System: is a health nurse-to-patient ratio important to the institution? 71. What are three essential components of quality care? - ANSWER 1. structure (environment in which care is provided) 2. process (nature and sequence of activities carried out by the nurse implementing the nursing process) 3. outcome (measurable and demonstrable changes in the health status of the patient of the results of nursing care) 72. What are 4 examples of the type of evaluations nurses are involved in as members of the health care team? - ANSWER 1. Nurses measure patient outcome achievment 2. Nurses measure how effectively nurses help targeted groups of patients achieve their specific goals 3. Nurses measure the competence of individual nurses 4. Nurses measure the degree to which external factors, such as different types of health care services, specialized equipment or procedures, or socioeconomic factors, influence health and wellness 73. A nurse evaluates patients prior to discharge from a hospital setting. What action would be the most important act of evaluation performed by the nurse? - ANSWER The nurse evaluates the patient's goals/outcome achievement 74. A nurse caring for an older adult patient who has dementia observes another nurse putting restraints on the patient without a health care provider's orders. The patient is agitated and not cooperating. What would be the best initial action of the first nurse in this situation? - ANSWER Confront the nurse and explain how this could be dangerous for the patient 75. Nurses formulate different types of goals for patients when planning patient care. What is considered a psychomotor patient goal? - ANSWER By 8/8/20, the patient will demonstrate improved motion in left arm 76. A nurse is evaluating nursing care and patient outcomes by using a retrospective evaluation. What would be an action the nurse would perform in this approach? - ANSWER The nurse devises a post discharge questionnaire to evaluate patient satisfaction 77. What is an action a nurse should take when patient data indicate that the stated goals have not been achieved? - ANSWER Review each preceding step of the nursing process 78. For a pt with self-care deficit, the long-term goal is that the pt will be able to dress himself by the end of the 6-week therapy. For best results, when should the nurse evaluate the patient's progress toward this goal? - ANSWER As soon as possible 79. The quality assurance model of the ANA identifies 3 essential components (structure, process, and outcome) of quality care. What is the component the nurse uses when determining whether a patient has met the goals stated on the care plan? - ANSWER outcome 80. What would be an appropriate action when evaluating a patient's responses to a care plan? - ANSWER Continue the care plan if more time is needed to achieve the goals/outcomes 81. Nurses formulate physiologic goals for patients when providing patient care. What are some examples of physiologic goals? - ANSWER -By 4/6/20, the baby will demonstrate adequate sleep wakefulness patterns -By 4/6/20, the baby will show an adequate comfort level indicating satisfactory parenting -Before discharge, the baby will have reached a target weight gain of 8 lb 82. A nurse is documenting evaluation of the care provided for an infant born with Down's Syndrome. What are some nursing actions that exemplify the appropriate documentation process? - ANSWER After the data have been collected to determine patient outcome achievement, the nurse writes an evaluative statement to summarize findings -The nurse writes a two-part evaluative statement that includes a decision about how well the outcome was met, along with patient data that support the decision -The nurse has three decision options for how goals have been met 83. A nurse is following the rules recommended by the Institute of Medicine's Committee on Quality of Health Care in America to help redesign and improve patient care. What are some nursing actions based on these rules? - ANSWER -The nurse bases care on evidence based decision making -The nurse promotes shared knowledge and the free flow of information -The nurse acknowledges that continuous decrease in waste improves patient care 84. A nurse manager attempts to achieve performance improvement in the ED of a busy inner-city hospital. What are examples of nursing actions that follow Haase and Miller's recommended steps in performance improvement? - ANSWER -A nurse discovers that there is a problem with the triage system that in in place in the ED -The nurse calls a meeting of the ED interdisciplinary team to affect change in the triage process -The nurse meets with the ED staff to assess changes made to the triage process 85. The primary source of the patient data is the patient. What are 2 other sources? - ANSWER 1. Patient support people 2. Patient record 86. the type of nursing assessment that is performed during the nurse's initial contact with the pt and involves collecting data about all aspects of the pt's health is called? - ANSWER initial assessment 87. When a nurse confirms or verifies the data collected upon assessment to keep it free of error, bias, or misinterpretation, he/she is performing the act of _____________. - ANSWER Validation 88. What is the health care tool practitioners can use to assess patient complexity using the social determinants of health, which affect the person's ability to manage his/her health? - ANSWER PCAM (patient centered assessment method) 89. A nurse who gathers data about a newly diagnosed case of HTN in a 52 year old patient is performing what type of assessment? - ANSWER Focused 90. When the nurse compares the current status of a patient to the initial assessment performed during the admitting process, what type of assessment is being performed? - ANSWER Time-lapsed 91. Most schools of nursing and health care institutions establish the specific information that must be collected from every patient in a structured assessment form. What is this information known as? - ANSWER Minimum data set 92. What are observable and measurable information that can be seen, heard, or felt by someone other than the person experiencing it? - ANSWER Objective data 93. What is the conscious and deliberate use of the five physical senses to gather information? - ANSWER Focused assessment 94. What clearly identifies patient strengths and weaknesses, health risks, and potential and existing health problems? - ANSWER Nursing history 95. What is a planned communication to obtain patient data? - ANSWER Interview 96. What is the examination of a patient for objective data that may better define the patient's condition and help the nurse in planning care? - ANSWER Physical Assessment 97. What is the act of confirming or verifying data? - ANSWER Validation 98. What type of assessment compares a patient's current status to baseline data obtained earlier? - ANSWER Time-lapsed 99. What includes all the pertinent patient information collected by the nurse and other health care professionals, enabling a comprehensive and effective plan of care to be designed and implemented for the patient? - ANSWER Database 100. What type of assessment gathers data about a specific problem that has already been identified? - ANSWER Forcused 101. What type of assessment may be used by nurses to help patients identify potential and actual health risks and to explore the habits, behaviors, beliefs, attitudes, and values that influence their health? - ANSWER Health assessment 102. Examples of objective data - ANSWER 1. redness/swelling at site of incision 103. 2. a pt has a violent coughing spell 104. 3. a pt recovering from knee surgery favors his impaired leg when walking 105. Examples of subjective data - ANSWER 1. a pt complains of pain in left arm 106. 2. a pt is nauseated at the site of food 107. 3. a pt worries about her children during a hospital stay 108. What are 5 functions of the initial comprehensive nursing assessment? - ANSWER 1. Make a judgment about a person's health status 109. 2. Make a judgment about a patient's ability to manage his/her own health care 110. 3. Refer the pt to a health care provider or other health care professional 111. 4. Make a judgment about a patient's need for nursing 112. 5. Plan and deliver thoughtful, person-centered, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being 113. What are 8 sources of patient data? - ANSWER 1. Patient 114. 2. Support people 115. 3. Patient record 116. 4. Medical hx, physical exam, & progress notes 117. 5. Lab reports/diagnostic studies 118. 6. Reports of therapies by other health care professionals 119. 7. Other health care professionals 120. 8. Nursing and other health care literature 121. Purposeful data - ANSWER The nurse identifies the purpose of the nursing assessment (comprehensive, focused, emergency, time lapsed) and then gathers the appropriate data 122. Prioritized data - ANSWER The nurse gets the more important information first 123. Complete data - ANSWER The nurse identifies all patient data to understand a patient's health problem and develop a care plan to maximize health promotion 124. Systematic data - ANSWER The nurse gathers the information in an organized manner 125. Accurate data - ANSWER The nurse continually verifies what is heard with what is observed and uses other senses to validate all questionable data 126. Relevant data - ANSWER The nurse determines what type of data and how much data to collect for each patient 127. Data recorded in a standard manner - ANSWER The nurse records the data according to facility policy so that all caregivers can easily access the data 128. What factors affect assessment priorities when collecting patient data? - ANSWER 1. Patient's health orientation (potential & actual health risks, habits, behaviors, beliefs, attitudes, and values that influence health) 129. 2. Patient's developmental stage 130. 3. Patient's culture 131. 4. Patient's need for nursing 132. What are two examples of when data needs to be validated? - ANSWER 1. When there are discrepancies 133. 2. When the data lacks objectivity 134. When is immediate communication of data indicated? - ANSWER Whenever assessment findings reveal a critical change I'm the patient's health status that necessitates the involvement of other nurses or health care professionals 135. Interview Process - ANSWER 1. The nurse prepares to meed the patient by reading current and past records and reports 136. 2. The nurse ensures the environment in which is to be conducted is private and relaxed 137. 3. The nurse initiates the interview by stating his/her name, identifying the purpose of the interview, and clarifying the roles of the nurse and patient 138. 4. The nurse assesses the patient's comfort and ability to participate in the interview 139. 5. The nurse gathers all the information needed to form the subjective database 140. 6. The nurse recapitulates the interview, highlighting key points 141. A nurse is conducting an interview with a patient who complains of abdominal distress. What is an appropriate interview question for this patient? - ANSWER What is your problem as you see it? 142. A nurse is interviewing a hospitalized patient. Which nurse-patient positioning facilitates an easy exchange of information 143. / - ANSWER If the patient is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed 144. A nurse is interviewing a new patient admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview? - ANSWER The nurse assesses the patient's comfort and ability to participate in the interview 145. A nurse is assessing a patient admitted to the hospital with complaints of left-sided weakness and difficulty speaking. Which assessment contains the data that best represents a nursing assessment? - ANSWER Patient is unable to communicate basic needs and cannot perform hygiene measures with left hand 146. During the nursing examination, the nurse notices that the patient, an older adult female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation? - ANSWER Ask the pt if it's ok to interview her husband for the answers to the interview questions 147. Nurses perform nursing assessment on patients as part of their routine care. What are examples that accurately describe the unique focus of these nursing assessments? - ANSWER -Nursing assessments focus on the patient's responses to health problems 148. -The findings from a nursing assessment may contribute to the identification of a medical diagnosis 149. -an initial assessment establishes a complete database for problem solving and care planning 150. Following a patient interview, the nurse is organizing data obtained according to Gordon's functional health pattern model. What are examples of statements that reflect the focus of this model? - ANSWER -Data are collected regarding the health perception/health management of the patient 151. -The perception of the major roles and responsibilities in the patient's life is explores 152. -Elimination, activity, sleep, and sexuality are components of the assessment and data collection 153. When a nurse writes a patient outcome that requires pain medication for goal achievement, the situation is a(n) _______ problem. - ANSWER Collaborative problem 154. Patient complains of chills and nausea are considered significant data or ___________. - ANSWER cues 155. When determining the significance of a patient's urinalysis, the normative values to which the data can be compared are termed a ___________? - ANSWER standard or norm 156. When a nurse groups patient cues that point to the existence of a patient health problem, the cues form what is known as a _____________. - ANSWER data cluster 157. When a nurse recognizes a cluster of significant patient data indicating that patient teaching and counseling for a colostomy is needed, a ______ should be written - ANSWER nursing diagnosis 158. What are two cues that must be present for a valid wellness diagnosis? - ANSWER 1. Desire for higher level of wellness 159. 2. An effective present status of function 160. What is a clinical judgement concerning a specific cluster of nursing diagnosis that occur together and are best addressed together and through similar interventions? - ANSWER a syndrome 161. Examples of identifying strengths and problems - ANSWER -A nurse notes that a patient's refusal to stop smoking will adversely affect his recovery from cardiac surgery 162. -A nurse determines that a man with a h/o diabetes is highly motivated to develop a healthy pattern of nutrition in response to his problem 163. Examples of recognizing significant data - ANSWER -A nurse compares a 15-month-old child's motor abilities with the norms for that age group 164. -A maternity nurse notices a newborn's skin tone is markedly different from that of the other babies and checks for jaundice 165. Example of recognizing patterns or clusters - ANSWER -A nurse recognizes an unhealthy situation developing when her patient, recovering from a mastectomy, cries at night, refuses to eat, and sleeps all day 166. Examples of reaching conclusions - ANSWER -A nurse decides no further nursing response is indicated for a women who recovered from gallbladder surgery according to schedule 167. -A nurse notices that a patient with AIDS has an adverse reaction to a drug and consults the prescribing health care provider 168. What are actual or potential health problems that can be prevented or resolved by independent nursing intervention? - ANSWER Nursing diagnosis 169. What represent situations that are the primary responsibility of the nurse? - ANSWER Nursing diagnosis 170. What is a generally accepted rule, measure, pattern, or model that can be used to compare data in the same class or category termed? - ANSWER Standard or norm 171. What is a grouping of pt data or cues that points to the existence of a patient health problem termed? - ANSWER data cluster 172. nursing diagnoses should be derived from a ______________ - ANSWER cluster of significant data 173. What is a beginning list of suggested terms for health problems that may be identified and treated by nurses termed? - ANSWER NANDA-I 174. What is part of a nursing diagnosis that identifies that physiological, psychological, sociological, spiritual, and environmental factors believed to be related to the problem as either a cause or contributing factor and directed nursing intervention termed? - ANSWER etiology 175. What is written when the nurse suspects that a health problem exists but needs to gather more data to confirm the diagnosis termed? - ANSWER a possible nursing diagnosis 176. What is a clinical judgement about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness termed? - ANSWER A wellness diagnosis 177. In the diagnosis step, the nurse __________ - ANSWER analyzes patient data 178. What is a clinical judgement about an individual, family, or community that is more likely to develop the problem than others in the same situation termed? - ANSWER risk diagnosis 179. Three examples of how standards may be used to identify significant cues - ANSWER -An infant who is below the normal growth standards for his age group may be experiencing "failure to thrive" 180. -A mother who has a h/o mental illness shows little or no interest in her baby 181. -A patient placed in a long-term facility by her son becomes incontinent without a physical cause 182. The formulation for nursing diagnosis is unique to the nursing profession. What is a statement that accurately represents a characteristic of diagnosing? - ANSWER Nurses write nursing diagnoses to describe patient problems that nurses can treat 183. A nurse documents that following in the pt chart: Risk for decreased cardiac output related to myocardial ischemia. This is an examples of what aspect of pt care? - ANSWER Nursing diagnosis 184. A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions d/t the parents' negligence in providing a safe environment. What is an example of an appropriate nursing diagnosis for this pt? - ANSWER Rick for injury r/t unsafe home environment 185. A nurse suspects that a patient has a self-care deficit but needs more data to confirm this diagnosis. What nursing diagnosis would the nurse write for this patient? - ANSWER A possible nursing diagnosis 186. What is an example of patient care that is not the responsibility of the nurse? - ANSWER Confirming a medical diagnosis 187. A student nurse is learning how to write a nursing diagnosis for a patient. What are examples of accurate guidelines when formulating nursing diagnoses? - ANSWER -Make sure the patient problem precedes the etiology 188. -Write the diagnosis in legally advisable terms 189. -Be sure the problem statement indicates what is unhealthy about the patient 190. -Make sure defining characteristics follow the etiology 191. Nurses write various types of nursing diagnoses depending on the patient's condition. What are examples of statements that accurately describe types of NANDA nursing diagnoses? - ANSWER -A risk nursing diagnosis is a clinical judgment that an individual, family, or community is more likely to develop the problem than others in the same or similar situation 192. -An actual diagnosis represents a problem that has been validated by the presence of major defining characteristics 193. -A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of certain events or situations 194. A nurse is writing nursing diagnosis for patients on a busy hospital ward. What are examples of nursing diagnoses that are written correctly? - ANSWER -Deficient fluid volume r/t abnormal fluid loss 195. -Risk for impaired skin integrity 196. -Risk for chronic low self-esteem 197. Nurses use approved NANDA-I nursing diagnoses when writing diagnoses for patients. What are examples of diagnoses that represent domain 1: health promotion as established by NANDA-I? - ANSWER -Ineffective health management 198. -Sedentary lifestyle 199. -Decreased diversional activity engagement 200. What are some nursing actions related to diagnosing the EHR enables the nurse to facilitate? - ANSWER -Viewing the pt's ongoing risks 201. -Deciding on and documenting new nursing diagnoses 202. -Facilitating communication of the pt's actual problems 203. -Making decisions about mutual patient goals and interventions 204. -Determining and documenting when the nursing diagnoses are resolved 205. What is an expected conclusion to a patient health problem or, in the event of wellness diagnosis, an expected conclusion to a patient's health expectation? - ANSWER Patient outcome 206. While driving to a restaurant for lunch, a nurse contemplates how to help a young cancer patient accept the loss of a limb. This nurse is using what process of planning? - ANSWER informal planning 207. In acute care settings, what are the three basic stages of planning that are critical to comprehensive nursing care? - ANSWER 1. initial 208. 2. ongoing 209. 3. discharge 210. From what part of the nursing diagnosis "Pain r/t delayed healing of surgical incision" would outcomes be derived? - ANSWER plan/the problem statement 211. What was developed by the Iowa Outcomes Project that presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention? - ANSWER Nursing Outcome Classification (NOC) 212. A nurse writes the following statement on a patient's chart: "Goal partially met; patient ate approximately one half of food offered for lunch." What kind of statement has she written? - ANSWER An evaluative statement 213. What is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes termed? - ANSWER Nursing intervention 214. When a nurse supplies education to an obese teenager regarding the fat content in food and helps him choose a nutritious diet, what kind of intervention is the nurse providing? - ANSWER nurse initiated intervention 215. When a nurse administers health care provider-prescribed pain medication to a patient after surgery, what type of intervention is the nurse providing? - ANSWER Health care provider initiated 216. What is a set of steps (typically embedded in a branching flowchart) that approximates the decision process of an expert clinician and is used to make a decision termed? - ANSWER An algorithm 217. What is a written guide that directed the efforts of the nursing team as the nurses work with patients to meet health goals? - ANSWER Nursing care plan 218. What type of care plan is developed by a nurse who performs the admission nursing history and physical assessment termed? - ANSWER initial care plan 219. Benefits of this care plan include ready access to an expanded knowledge base, improved record keeping and documentation, and decreased paperwork - ANSWER Computerized care plan 220. The chide purpose of this type of planning is to keep the plan up to date - ANSWER ongoing problem-solving care plan 221. What are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population of heath problem called? - ANSWER standardized care plan 222. This type of plan for leaving the institution is best prepared by the nurse who has worked most closely with the patient, in conjunction with a social worker familiar with the patient's community - ANSWER discharge care plan 223. The emphasis of this care plan is to clearly state expected patient outcomes and the specific times by which it is reasonable to achieve these outcomes - ANSWER clinical pathways 224. The emphasis of this type of care plan is to individualize the plan to meet unique patient needs - ANSWER ongoing problem-solving care plan 225. This diagram of patient problems and interventions is used to organize data, analyze data, and take a holistic view of the patient situation - ANSWER concept map care plan 226. What are some examples of cognitive goals? - ANSWER -By 3/30/20, the patient will list 5 low fat snacks to replace high-fat foods 227. -By 3/30/20, the patient will list 3 reasons to continue taking blood pressure medication