HESI RN Fundamentals Exam B

HESI RN Fundamentals Exam B 1. What is the rationale for using the nursing process in planning care for clients? A. As a scientific process to identify nursing diagnoses of a clients' healthcare problems. B. To establish nursing theory that incorporates the biopsychosocial nature of humans. C. As a tool to organize thinking and clinical decision making about clients' healthcare needs. D. To promote the management of client care in collaboration with other healthcare professionals. C (The nursing process is a problem-solving approach that provides an organized, systematic, decision making process to effectively address the client's needs and problems. The nursing process includes an organized framework using knowledge, judgments, and actions by the nurse as the client's plan of care is determined, and encompasses assessment, analysis, planning, implementation, and evaluation of client care (C). (A, B, and D) do not support the basis for using the nursing process. Correct Answer: C) 2. What activity should the nurse use in the evaluation phase of the nursing process? A. Ask a client to evaluate the nursing care provided. B. Document the nursing care plan in the progress notes. C. Determine whether a client's health problems have been alleviated. D. Examine the effectiveness of nursing interventions toward meeting client outcomes. In the nursing process, the evaluation component examines the effectiveness of nursing interventions in achieving client outcomes (D). (A) is an evaluation of client satisfaction, not outcomes. (B) is a written record of the plan of care. Although (C) may occur when client outcomes are achieved, evaluation is best determined by attainment of measurable client outcomes. Correct Answer: D 3. Which statement is an example of a correctly written nursing diagnosis statement? A. Altered tissue perfusion related to congestive heart failure. B. Altered urinary elimination related to urinary tract infection. C. Risk for impaired tissue integrity related to client's refusal to turn. D. Ineffective coping related to response to positive biopsy test results. The first part of the nursing diagnosis statement is the diagnostic label and is followed by related to the cause, which should direct the nurse to the appropriate interventions. (D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause, but (D) focuses on the client's response, which the nurse can provide support, reflection, and dialogue. Correct Answer: D 4. What action by the nurse demonstrates culturally sensitive care? A. Asks permission before touching a client. B. Avoids questions about male-female relationships. C. Explains the differences between Western medical care and cultural folk remedies. D. Applies knowledge of a cultural group unless a client embraces Western customs. Physical contact, such as touching the head, in some cultures is a sign of respect, whereas in others, it is strictly forbidden. So asking permission before touching a client (A) demonstrates culturally sensitive care. (B, C, and D) do not demonstrate cultural awareness. Correct Answer: A 5.A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? A. Suggest that other cultural practices be substituted by the family members. B. Examine one's own culturally based values, beliefs, attitudes, and practices. C. Explain to the family that multiple visitors are exhausting to the client. D. Allow the situation to continue until a family member's action may harm the client. Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values (B) to compare, recognize, and acknowledge cultural bias. (A and C) do not consider the family's needs to care for the client and are not the best ways to cope with the nurse's frustration. Although (D) may be an option, examining one's cultural differences allows the nurse to cope, empathize, and implement culturally specific interventions pertaining to the needs of the client and the family. Correct Answer: B