NURS 2700 EXAM 1 QUESTIONS WITH COMPLETE
SOLUTIONS
A 15-year-old client tells the nurse that he wishes to make his
own medical decisions. Which is the nurse's best response?
A."If you want to make your own healthcare decisions, you will
need to consult an attorney."
B."Your parents will need to sign the consent form until you
turn 18 years of age."
C."You will need to provide written consent for procedures in
addition to your parents giving consent."
D."You can sign the legal consent form if you prefer and make
the medical decisions for your care." Correct Answer A.
Rationale: The teen will need to consult with an attorney to gain
the legal right to medical autonomy. Although it is correct that
teens under the age of 18 will need their parent or legal guardian
to make their medical decisions and sign consent forms, it is not
a complete answer and does not help the teen. There is no
written consent form for the adolescent to sign.
A 52-year-old male client with heart failure, renal failure, and
diabetes has bilateral pedal edema. When creating the concept
map, which information should the nurse place in the center of
the map? (Select all that apply.)
A.Presence of edema
B.Age
C.Medical diagnoses
D.Report of pain
E.Sex
F.Vital signs Correct Answer B,C,E
,Rationale: A shape with the client's age, sex, and medical
diagnoses is placed in the middle of the map to illustrate the
client-centered nature of nursing care. The client's initials are
also included. Vital signs, complaints of pain, and the presence
of edema are assessment data that the nurse will use to create
data clusters.
Next Question
A client diagnosed with a respiratory illness presents with
shortness of breath. Which type of assessment is the priority for
this client?
A.
Auscultation
B.
Inspection
C.
Percussion
D.
Palpation Correct Answer A.
Rationale: Auscultation is the process of listening to sounds
produced within the body. This type of assessment would be a
priority for a client who is experiencing respiratory difficulty.
While inspection, palpation, and percussion may also be useful
in the assessment of this client, auscultation takes priority.
A group of nurses from a hospital's emergency department is
very close-knit. Which characteristic of the group classifies it as
a primary group? (Select all that apply.)
A.Spontaneity
B.Impersonal communication
C.Face-to-face communication time
, D.Task-oriented approach
E.Unity Correct Answer A,C,E
Rationale: Primary groups are small and intimate groups where
the group members have a relationship that can be personal,
spontaneous, sentimental, cooperative, and inclusive.
Communication in this group is primarily face to face. The
individuals support each other during stressful situations as
group members develop unity and "oneness" and adopt a sense
of "we" and "our." Secondary groups focus on a task and
communicate by impersonal means, not face to face.
OK
A healthcare organization is adopting the use of a three-column
nursing plan of care. Which information should be documented
in these columns? (Select all that apply.)
A.Goals/desired outcomes
B.Nursing interventions
C.Evaluation
D.Nursing diagnoses
E.Assessment Correct Answer A,B,D
Rationale: This type of plan of care identifies a column for data
that corresponds to each phase of the nursing process. For a
three-column plan, the columns are nursing diagnosis,
goals/desired outcomes, and nursing interventions. Evaluation is
a part of a four- or five-column plan. Assessment is a part of a
five-column plan.
A new nurse asks for help with clinical reasoning. Which
suggestion should the nurse provide?
A.
SOLUTIONS
A 15-year-old client tells the nurse that he wishes to make his
own medical decisions. Which is the nurse's best response?
A."If you want to make your own healthcare decisions, you will
need to consult an attorney."
B."Your parents will need to sign the consent form until you
turn 18 years of age."
C."You will need to provide written consent for procedures in
addition to your parents giving consent."
D."You can sign the legal consent form if you prefer and make
the medical decisions for your care." Correct Answer A.
Rationale: The teen will need to consult with an attorney to gain
the legal right to medical autonomy. Although it is correct that
teens under the age of 18 will need their parent or legal guardian
to make their medical decisions and sign consent forms, it is not
a complete answer and does not help the teen. There is no
written consent form for the adolescent to sign.
A 52-year-old male client with heart failure, renal failure, and
diabetes has bilateral pedal edema. When creating the concept
map, which information should the nurse place in the center of
the map? (Select all that apply.)
A.Presence of edema
B.Age
C.Medical diagnoses
D.Report of pain
E.Sex
F.Vital signs Correct Answer B,C,E
,Rationale: A shape with the client's age, sex, and medical
diagnoses is placed in the middle of the map to illustrate the
client-centered nature of nursing care. The client's initials are
also included. Vital signs, complaints of pain, and the presence
of edema are assessment data that the nurse will use to create
data clusters.
Next Question
A client diagnosed with a respiratory illness presents with
shortness of breath. Which type of assessment is the priority for
this client?
A.
Auscultation
B.
Inspection
C.
Percussion
D.
Palpation Correct Answer A.
Rationale: Auscultation is the process of listening to sounds
produced within the body. This type of assessment would be a
priority for a client who is experiencing respiratory difficulty.
While inspection, palpation, and percussion may also be useful
in the assessment of this client, auscultation takes priority.
A group of nurses from a hospital's emergency department is
very close-knit. Which characteristic of the group classifies it as
a primary group? (Select all that apply.)
A.Spontaneity
B.Impersonal communication
C.Face-to-face communication time
, D.Task-oriented approach
E.Unity Correct Answer A,C,E
Rationale: Primary groups are small and intimate groups where
the group members have a relationship that can be personal,
spontaneous, sentimental, cooperative, and inclusive.
Communication in this group is primarily face to face. The
individuals support each other during stressful situations as
group members develop unity and "oneness" and adopt a sense
of "we" and "our." Secondary groups focus on a task and
communicate by impersonal means, not face to face.
OK
A healthcare organization is adopting the use of a three-column
nursing plan of care. Which information should be documented
in these columns? (Select all that apply.)
A.Goals/desired outcomes
B.Nursing interventions
C.Evaluation
D.Nursing diagnoses
E.Assessment Correct Answer A,B,D
Rationale: This type of plan of care identifies a column for data
that corresponds to each phase of the nursing process. For a
three-column plan, the columns are nursing diagnosis,
goals/desired outcomes, and nursing interventions. Evaluation is
a part of a four- or five-column plan. Assessment is a part of a
five-column plan.
A new nurse asks for help with clinical reasoning. Which
suggestion should the nurse provide?
A.
