for Clinical Judgment and Collaborative Care
11th Edition by Donna D. Ignatavicius,
All chapters 1 - 74
,
,
, Chapter 01: Overview of Professional Nursing Concepts for Medical-
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MULTIPLE CHOICE Ap
1. A nurse wishes to provide client-centered care in all interactions. Which action by the
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Ap nurse best demonstrates this concept?
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a. Assesses for cultural influences affecting health care
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b. Ensures that all the clients basic needs are met
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c. Tells the client and family about all upcoming tests
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d. Thoroughly orients the client and family to the room
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CORRECT ANSWER: A Ap Ap
Competency in client-focused care is demonstrated when the nurse focuses on communication, culture,
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Ap respect compassion, client education, and empowerment. By assessing the effect of the clients
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Ap culture on health care, this nurse is practicing client-focused care. Providing for basic needs does
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Ap not demonstrate this competence. Simply telling the client about all upcoming tests is not providing
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empowering education. Orienting the client and family to the room is an important safety measure,
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Ap but not directly related to demonstrating client-centered care.
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DIF: Understanding/Comprehension REF: 3
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KEY: Patient-centered care| culture MSC: Integrated Process:
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Ap Caring NOT: Client Needs Category: Psychosocial Integrity
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2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was
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Ap 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
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a. Call the Rapid Response Team.
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b. Document and continue to monitor. Ap Ap Ap Ap
c. Notify the primary care provider.
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d. Repeat blood pressure measurement in 15 minutes.
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CORRECT ANSWER: A Ap Ap
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating
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Ap before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant
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Ap change, the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and
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Ap pain are particularly significant.
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Documentation is vital, but the nurse must do more than document. The primary care provider
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should be notified, but this is not the priority over calling the RRT. The clients blood pressure
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Ap should be reassessed frequently, but the priority is getting the rapid care to the client.
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DIF: Applying/Application REF: 3
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KEY: Rapid Response Team (RRT)| medical emergencies
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A p MSC: Integrated Process: Communication and
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