NURS 221 Midterm Exam - Questions With Well
Explained Solutions
A patient is preparing for discharge following hip surgery and the
patient will likely require extensive physiotherapy. What
assessment question should the nurse prioritize? Right Answer
- "Are you able to pay for the costs of your physiotherapy
treatments?"
A nurse is providing care for a patient who has undergone a partial
foot amputation for the treatment of osteomyelitis (bone infection).
The nurse observes that the patient will not look at her foot when
the nurse changes the dressing. How should the nurse best follow up
this observation? Right Answer - Gather more data to better
understand the patient's behaviour.
A nurse is interviewing a new client admitted to the hospital for
surgery. Which action would the nurse perform in the introductory
phase of the interview? Right Answer - The nurse assesses the
client's comfort and ability to participate in the interview.
A client who gave birth yesterday refuses to eat the food provided
by the hospital. She states that she must eat special food brought
from home by her family. How would the nurse most appropriately
address this situation? Right Answer - The nurse should plan
no action because the client is not exhibiting a health problem.
A client who is scheduled for coronary angioplasty is concerned if
the surgery is safe and wonders whether it would be beneficial to
him. Which nursing diagnosis relates to this client's condition?
Right Answer - Fear related to potential risk and surgical outcomes
,A client with a new colostomy often becomes short and sarcastic
when nurses attempt to teach him about the management of his new
appliance. The nurse has consequently documented
"Noncompliance related hostility" on the client's chart. What
mistake has the nurse made when choosing and documenting this
nursing diagnosis? Right Answer - presuming to know the
factors contributing to the problem
A nurse is reviewing the plan of care for a client and notes the
following: "The client verbalizes three signs of hypoglycemia to the
staff accurately before discharge." The nurse interprets this
statement as a(n): Right Answer - outcome criteria
A client with multiple leg fractures following a motor vehicle
accident tells the nurse, "I am going crazy here. I have to wait 2
months before I can practice walking, again." What is the priority
nursing diagnosis? Right Answer - deficient diversional
activity
A preceptor reviews the client outcomes written by a new nurse.
Which outcome is the priority for the client with paranoid
delusions? Right Answer - Within 3 days, client will mingle in
the day room without violence.
The home health nurse caring for a client with limited eyesight
notes that the client's route to the bathroom is cluttered. What is the
most effective way for the nurse to ensure the client's long-term
safety? Right Answer - Assist the client to identify strategies to
promote safety in the home.
The nurse is preparing to implement plans of care with several
clients. Which action would be inappropriate for the nurse to
perform? Right Answer - Respond to the postoperative client's
question that baths are given only in the morning.
, A nurse in the ICU (intensive care unit) has been assigned to care for
a client who was seriously injured during a gang rape. The nurse
was raped 6 months ago and feels that she will be too upset to care
for the client properly. How should the nurse deal with the
assignment? Right Answer - Recognize her limitations and ask
for another nurse to be assigned.
A client has a nursing diagnosis of Possible Spiritual Distress. What
is the most appropriate nursing intervention? Right Answer -
Discuss spirituality with the client.
A nurse just reported to the oncoming shift that she had failed to do
an ordered dressing change. She reported to the nurse manager that
this was the second time this week she had not had time to do the
dressing change. The nurse manager recognized that the nurse
normally was very punctual and was known to provide good care
for her clients however the unit census had been very high on this
particular week. The nurse manager knows that quality care must
be provided and reports this occurrence as what type of quality
approach? Right Answer - Quality by opportunity
The nurse is caring for Mr. H., a 35-year-old man who is hospitalized
following a motorcycle accident. He has a traumatic brain injury.
The nurse is working with Mr. H. on self-care behaviors. The
following would help the nurse to assess the success of the nursing
interventions except which of the following? Right Answer -
Model self-care behaviors for the client.
Which action should the nurse take when client data indicate that
the stated goals have not been achieved? Right Answer -
Review each preceding step of the nursing process.
Explained Solutions
A patient is preparing for discharge following hip surgery and the
patient will likely require extensive physiotherapy. What
assessment question should the nurse prioritize? Right Answer
- "Are you able to pay for the costs of your physiotherapy
treatments?"
A nurse is providing care for a patient who has undergone a partial
foot amputation for the treatment of osteomyelitis (bone infection).
The nurse observes that the patient will not look at her foot when
the nurse changes the dressing. How should the nurse best follow up
this observation? Right Answer - Gather more data to better
understand the patient's behaviour.
A nurse is interviewing a new client admitted to the hospital for
surgery. Which action would the nurse perform in the introductory
phase of the interview? Right Answer - The nurse assesses the
client's comfort and ability to participate in the interview.
A client who gave birth yesterday refuses to eat the food provided
by the hospital. She states that she must eat special food brought
from home by her family. How would the nurse most appropriately
address this situation? Right Answer - The nurse should plan
no action because the client is not exhibiting a health problem.
A client who is scheduled for coronary angioplasty is concerned if
the surgery is safe and wonders whether it would be beneficial to
him. Which nursing diagnosis relates to this client's condition?
Right Answer - Fear related to potential risk and surgical outcomes
,A client with a new colostomy often becomes short and sarcastic
when nurses attempt to teach him about the management of his new
appliance. The nurse has consequently documented
"Noncompliance related hostility" on the client's chart. What
mistake has the nurse made when choosing and documenting this
nursing diagnosis? Right Answer - presuming to know the
factors contributing to the problem
A nurse is reviewing the plan of care for a client and notes the
following: "The client verbalizes three signs of hypoglycemia to the
staff accurately before discharge." The nurse interprets this
statement as a(n): Right Answer - outcome criteria
A client with multiple leg fractures following a motor vehicle
accident tells the nurse, "I am going crazy here. I have to wait 2
months before I can practice walking, again." What is the priority
nursing diagnosis? Right Answer - deficient diversional
activity
A preceptor reviews the client outcomes written by a new nurse.
Which outcome is the priority for the client with paranoid
delusions? Right Answer - Within 3 days, client will mingle in
the day room without violence.
The home health nurse caring for a client with limited eyesight
notes that the client's route to the bathroom is cluttered. What is the
most effective way for the nurse to ensure the client's long-term
safety? Right Answer - Assist the client to identify strategies to
promote safety in the home.
The nurse is preparing to implement plans of care with several
clients. Which action would be inappropriate for the nurse to
perform? Right Answer - Respond to the postoperative client's
question that baths are given only in the morning.
, A nurse in the ICU (intensive care unit) has been assigned to care for
a client who was seriously injured during a gang rape. The nurse
was raped 6 months ago and feels that she will be too upset to care
for the client properly. How should the nurse deal with the
assignment? Right Answer - Recognize her limitations and ask
for another nurse to be assigned.
A client has a nursing diagnosis of Possible Spiritual Distress. What
is the most appropriate nursing intervention? Right Answer -
Discuss spirituality with the client.
A nurse just reported to the oncoming shift that she had failed to do
an ordered dressing change. She reported to the nurse manager that
this was the second time this week she had not had time to do the
dressing change. The nurse manager recognized that the nurse
normally was very punctual and was known to provide good care
for her clients however the unit census had been very high on this
particular week. The nurse manager knows that quality care must
be provided and reports this occurrence as what type of quality
approach? Right Answer - Quality by opportunity
The nurse is caring for Mr. H., a 35-year-old man who is hospitalized
following a motorcycle accident. He has a traumatic brain injury.
The nurse is working with Mr. H. on self-care behaviors. The
following would help the nurse to assess the success of the nursing
interventions except which of the following? Right Answer -
Model self-care behaviors for the client.
Which action should the nurse take when client data indicate that
the stated goals have not been achieved? Right Answer -
Review each preceding step of the nursing process.
