NURSING MISC Foundations-Midterm Exam,100% CORRECT

Chapter 02: The Health Care Delivery System 1. The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient? 2. A nurse is teaching the staff about managed care. Which information should the nurse include in the teaching session? 3. A nurse is teaching a family about health care plans. Which information from the nurse indicates a correct understanding of the Affordable Care Act? 4. A nurse is caring for a patient in the hospital. When should the nurse begin discharge planning? 5. The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In which type of health care facility does the nurse want to work? 6. A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing? 7. A nurse is following the PDSA cycle for quality improvement. Which action will the nurse take for the letter “A”? 8. The nurse is trying to determine how well a certain health plan compares with other health plans. To gather this type of data, which information will the nurse utilize? 9. An older adult patient has extensive wound care needs after discharge from the hospital. Which facility should the nurse discuss with the patient? 10. A nurse working in a community hospital’s emergency department provides care to a patient having chest pain. Which level of care is the nurse providing? 11. A nurse is teaching about the effects of globalization. Which information should the nurse include in the teaching session? 12. A nurse is using research findings to improve clinical practice. Which technique is the nurse using? 13. Which finding indicates the best quality improvement process? 14. A nurse is providing home care to a home-bound patient treated with intravenous (IV) therapy and enteral nutrition. What is the home health nurse’s primary objective? 15. A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse’sbest response? 16. A nurse is completing a minimum data set. Which area is the nurse working? MULTIPLE RESPONSE 1. Which government-instituted programs should the nurse include in a teaching session about controlling health care costs? (Select all that apply.) 2. A nurse is teaching the staff about the Institute of Medicine competencies. Which examples indicate the staff has a correct understanding of the teaching? (Select all that apply.) 3. A nurse is evaluating care based upon the nursing quality indicators. Which areas should the nurse evaluate? (Select all that apply.) 4. A nurse is working in a health care organization that has achieved Magnet status. Which components are indicators of this status? (Select all that apply.) MATCHING A nurse is teaching about the different types of health care plans. Match the correct information to the type of health care plans the nurse should include in the teaching session. a. Insurance for low-income families b. Federal insurance for people aged 65 and older c. Health maintenance focus to specific group of voluntarily enrolled people d. Services at a discount for companies under contract 1. Preferred provider organization 2. Managed care organization 3. Medicaid 4. Medicare 1.ANSDIF:Understand (comprehension)REF:15-16 OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning MSC:Management of Care 2.ANS:CDIF:Understand (comprehension)REF:15-16 OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning MSC:Management of Care 3.ANS:ADIF:Understand (comprehension)REF:15-16 OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning MSC:Management of Care 4.ANS:BDIF:Understand (comprehension)REF:15-16 OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning MSC:Management of Care Free Chapter 03: Community-Based Nursing Practice 1. A nurse is working as a public health nurse. What will be the nurse’s primary focus? 2. A nurse wants to become a specialist in public health nursing. Which educational requirement will the nurse have to obtain? 3. A nurse is working as a community health nurse. Which action is a priority for this nurse? 4. A nurse is focusing on acute and chronic care of individuals and families within a community while enhancing patient autonomy. Which type of nursing care is the nurse providing? 5. The community health nurse is administering flu shots to children at a local playground. What is the rationale for this nurse’s action? 6. A nurse attended a seminar on community-based health care. Which information indicates the nurse has a good understanding of community-based health care? 7. A nurse is using the Healthy People 2020 to establish goals for the community. Which goal ispriority? 8. A nurse is working in community-based nursing. Which competency is priority for this nurse? 9. A nurse observes an outbreak of lice in a certain school district. The nurse collects data and identifies a common practice of sharing lockers, caps, and hair brushes. The nurse shares the information with the school. Which community-based nursing competency did the nurse use? 10. A nurse is providing screening at a health fair. Which finding indicates the person may be a vulnerable patient who is most likely to develop health problems? 11. The instructor is teaching student nurses about identifying members of vulnerable populations when the nursing student asks, “Why is it that not all poor people are considered members of vulnerable populations?” How should the nurse respond? 12. The nurse is making a home visit to a Korean mother after the birth of girl. The spouse is pressing different parts of the patient’s hand and lower arm to relieve a headache. What is the nurse’s next action? 13. A nurse is assessing the social system of a community. Which area should the nurse assess? 14. The nurse is working with a 16-year-old pregnant female who tells the nurse that she needs an abortion. The nurse, acting as a counselor, provides the patient with information on alternatives to abortion, but after several sessions, the patient still insists on having the abortion. What should the nurse, in the counselor role, do next? 15. Before a patient with beginning stage of Alzheimer’s disease is discharged, the community-based nurse is making a visit to the patient’s home. The patient’s daughter and family live in the home with the patient. What is the major focus of this visit? 17. The nurse uses statistics on increased incidence of communicable disease to influence legislatures to pass a bill for mandatory vaccinations to enroll in school. Which type of nursing will the nurse use in this process? MULTIPLE RESPONSE 1. A community-based nursing is working with a family. For which key areas will the nurse need a strong knowledge base? (Select all that apply.) 2. Which community-based nursing activities indicate the nurse is working in the role of educator? (Select all that apply.) 3. A nurse is caring for vulnerable populations in a local community. Which patients will the nurse care for in this community? (Select all that apply.) MATCHING A nurse is assessing a community. Match each community element the nurse will assess with the correct example. a. Education level b. Housing c. Government 1. Structure 2. Population 3. Social system 1.ANS:BDIF:Understand (comprehension)REF:38 OBJ: Describe elements of a community assessment. TOP: Assessment MSC:Health Promotion and Maintenance 2.ANS:ADIF:Understand (comprehension)REF:38 OBJ: Describe elements of a community assessment. TOP: Assessment MSC:Health Promotion and Maintenance 3.ANS:CDIF:Understand (comprehension)REF:38 OBJ: Describe elements of a community assessment. TOP: Assessment MSC:Health Promotion and Maintenance Chapter 04: Theoretical Foundations of Nursing Practice 1. The nursing instructor is teaching a class on nursing theory. One of the students asks, “Why do we need to know this stuff? It doesn’t really affect patients.” What is the instructor’s bestresponse? 2. The nurse is caring for a patient who does not follow the prescribed regimen for diabetes management. As a prescriber to Orem’s theory, the nurse interviews the patient in an attempt to identify the cause of the patient’s “noncompliance.” What is the rationale for the nurse’s behavior? 3. A nurse is testing meditation for migraine headaches and the expected outcome of care when performing this intervention. Which type of theory is the nurse using? 4. The nurse researcher is evaluating whether holding pressure at an injection site after injecting the anticoagulant enoxaparin will reduce bruising at the injection site. This study involves a prescriptive theory. What is the nurse’s rationale for involving a prescriptive theory? 5. A nurse is using nursing theory and the nursing process simultaneously to plan nursing care. How will the nurse use nursing theory and the nursing process in practice? 6. The nurse views the patient as an open system that needs help in coping with stressors. Which theorist is the nurse using? 7. The nurse is caring for a patient diagnosed with essential hypertension. The health care provider prescribes blood pressure medication that the nurse administers. The nurse then monitors the patient’s blood pressure for several days to help determine effectiveness. Which system component is the nurse evaluating? 8. A patient is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA) and is placed in isolation until cultures can be obtained and declared noninfectious. During the isolation process, the nurse encourages family visits. Which level of Maslow’s hierarchy of needs is the nurse promoting when the family is encouraged to visit? 9. A nurse is caring for pediatric patients and using the developmental theory to plan nursing care. What is the focus of this nurse’s care? 10. Upon assessment, the nurse notices that the patient’s respirations have increased, and the tip of the nose and earlobes are becoming cyanotic. The nurse finds that the patient’s pulse rate is over 100 beats per minute. According to Maslow’s hierarchy of needs, which patient need should the nurse address first? 11. Which behavior from a nurse indicates the nurse is using Nightingale’s theory to plan nursing care? 12. The home health nurse listens to the patient’s concerns about having “open-heart” surgery. The nurse explains the different surgical procedures and other options, like cardiac rehabilitation. After several visits, the patient wants cardiac rehabilitation. The nurse notifies the health care provider and sets up a referral. Which theory is the nurse using? 13. The nurse is caring for a patient who is actively bleeding. The health care provider prescribes blood transfusions. The patient is a Jehovah’s Witness and does not want blood products. The nurse contacts the health care provider to request alternative treatment. Which theory is the nurse using? 14. The patient is terminally ill and is receiving hospice care. The nurse cares for the patient by bathing, shaving, and repositioning him. The patient would like a Catholic priest called to provide the Sacrament of the Sick. The nurse places a call and arranges for the priest’s visit. Which theory does this nurse’s care represent? 15. The patient is newly diagnosed with diabetes and will be discharged in the next day or so. The nurse is teaching the patient how to draw up and self-administer insulin. Which nursing theory is the nurse utilizing? 16. A nurse is conducting research about the needs of depressed patients. The nurse writes the following: Depression is a patient reporting a score above 7 on the Hamilton Depression Rating Scale. What did the nurse write? 17. Which action indicates the nurse is using the nursing process in patient care? 18. A nurse is using theoretical knowledge in nursing practice to provide patient care. Which nursing behavior is an example of theoretical knowledge? 19. A nurse is using Maslow’s hierarchy of needs to prioritize care. Place the levels in order of basic priority to highest priority that the nurse will follow. MULTIPLE RESPONSE 1. A nurse is using a nursing metaparadigm to define nursing. Which concepts will the nurse include? (Select all that apply.) 2. A nurse wants to incorporate psychosocial theories into nursing practice. Which elements will the nurse include? (Select all that apply.) Chapter 05: Evidence-Based Practice 1. A nurse uses evidence-based practice (EBP) to provide nursing care. What is the bestrationale for the nurse’s behavior? 2. In caring for patients, what must the nurse remember about evidence-based practice (EBP)? 3. A nurse wants to change a patient procedure. Which action will the nurse take to easily find research evidence to support this change? 4. A nurse has collected several research findings for evidence-based practice. Which article will be the best for the nurse to use? 5. The nurse is reviewing a research article on a patient care topic. Which area should entice the nurse to read the article? 6. The nurse is caring for a patient with chronic low back pain. The nurse wants to determine the best evidence-based practice regarding clinical guidelines for low back pain. What is thebest database for the nurse to access? 7. A nurse writes the following PICOT question: How do patients with breast cancer rate their quality of life? How should the nurse evaluate this question? 8. A nurse is reviewing literature for an evidence-based practice study. Which study should the nurse use for the most reliable level of evidence that uses statistics to show effectiveness? The main difference is that in a meta-analysis the researcher uses statistics to show the effect of an intervention on an outcome. In a systematic review no statistics are used to draw conclusions about the evidence. A single random controlled trial (RCT) is not as conclusive as a review of several RCTs on the same question. Control trials without randomization may involve bias in how the study is conducted. 9. A nurse is reviewing research studies for evidence-based practice. Which article should the nurse use for qualitative nursing research? 10. A nurse develops the following PICOT question: Do patients who listen to music achieve better control of their anxiety and pain after surgery when compared with patients who receive standard nursing care following surgery? Which information will the nurse use as the “C”? 11. The nurse uses a PICOT question to develop an evidence-based change in protocol for a certain nursing procedure. However, to make these changes throughout the entire institution would require more evidence than is available at this time. What is the nurse’s best option? 12. The nurse is trying to identify common general themes relative to the effectiveness of cardiac rehabilitation from patients who have had heart attacks and have gone through cardiac rehabilitation programs. The nurse conducts interviews and focus groups. Which type of research is the nurse conducting? 13. In conducting a research study, the nurse researcher guarantees the subject no information will be reported in any manner that will identify the subject and only the research team will have access to the information. Which concept is the nurse researcher fulfilling? 14. The nurse researcher is preparing to publish the findings and is preparing to add the limitations to the manuscript. Which area of the manuscript will the nurse researcher add this information? 15. A nurse is trying to decrease the rate of falls on the unit. After reviewing the literature, a strategy is implemented on the unit. After 3 months, the nurse finds that the falls have decreased. Which process did the nurse institute? 16. A nurse identifies a clinical problem with pressure ulcers. Which step should the nurse take next in the research process? 17. After reviewing the literature, the evidence-based practice committee institutes a practice change that bedrails should be left in the down position and hourly nursing rounds should be conducted. The results indicate over a 40% reduction in falls. What is the committee’s next step? 18. A nurse is developing a care delivery outcomes research project. Which population will the nurse study? 19. A nurse is implementing an evidence-based practice project regarding infection rates. After reviewing research literature, which other evidence should the nurse review? When implementing an evidence-based practice project, it is important to first review evidence from appropriate research and quality improvement data. Inductive reasoning is used to develop generalizations or theories from specific observations; this study needs specifics. Informed consent is not data but a process and form that subjects must sign before participating in research projects/studies. Biased data is based on opinions; facts are needed for this study. DIF:Understand (comprehension)REF:61 OBJ: Explain the relationship between evidence-based practice and performance improvement. TOP:ImplementationMSC:Management of Care 20. A nurse is using the research process. Place in order the sequence that the nurse will follow. 1. Analyze results. 2. Conduct the study. 3. Identify clinical problem. 4. Develop research question. 5. Determine how study will be conducted. MULTIPLE RESPONSE 1. The nurse is preparing to conduct research that will allow precise measurement of a phenomenon. Which methods will provide the nurse with the right kind of data? (Select all that apply.) 2. Before conducting any study with human subjects, the nurse researcher must obtain informed consent. What must the nurse researcher ensure to obtain informed consent? (Select all that apply.) 3. The nurse is reviewing nursing research literature related to a potential practice problem on the nursing unit. What is the rationale for the nurse’s action? (Select all that apply.) a. Nursing research ensures the nurse’s promotion. b. Nursing research identifies new knowledge. c. Nursing research improves professional practice. d. Nursing research enhances effective use of resources. e. Nursing research leads to decreases in budget expenditures. Chapter 06: Health and Wellness 1. A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session? 2. A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take? 3. A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care? 4. The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? 5. A nurse is using Maslow’s hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? 6. The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? 7. A nurse is assessing internal variables that are affecting the patient’s health status. Which area should the nurse assess? 8. The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse’s actions? 9. The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering? 10. The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? 11. The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving? 12. A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving? 13. Upon completing a history, the nurse finds that a patient has risk factors for lung disease. How should the nurse interpret this finding? 14. The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? 15. The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient for “detox.” What should the nurse do next? 16. A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? 17. Upon completion of the assessment, the nurse finds that the patient has quit drinking and has been alcohol free for the past 2 years. Which stage best describes the nurse’s assessment finding? 18. The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and spouse refuse to talk about it and refuse to be taught about how to care for it. How will the nurse evaluate this couple’s stage of adjustment? 19. A patient has had emphysema (lung disease) for many years. When approached by the nurse, the patient states “I would be better off dead.” The patient supports the family, and now because of oxygen dependency the patient must quit work. The patient’s spouse will have to go to work. Which action should the nurse take? 20. A nurse is teaching about the transtheoretical model of change. In which order will the nurse place the progression of the stages from beginning to end? 1. Action 2. Preparation 3. Maintenance 4. Contemplation 5. Precontemplation MULTIPLE RESPONSE 1. Which areas should the nurse assess to determine the effects of external variables on a patient’s illness? (Select all that apply.) 2. A nurse meets the following goals: helps a patient maintain health and helps a patient with an illness. Which factors assist the nurse in achieving these goals? (Select all that apply.) Chapter 07: Caring in Nursing Practice 1. A nurse is caring for a patient in pain. Which nursing approach is priority? 2. A nurse is providing pain medication to patients after surgery. Which component is key for the nurse’s personal philosophy of nursing? 3. A nurse attends a seminar on nursing theories for caring. Which information from the nurse indicates a correct understanding of these theories? 4. The patient has a colostomy but has not yet been able to look at it. The nurse teaches the patient how to care for the colostomy. The nurse sits with the patient, and together they form a plan on how to approach dealing with colostomy care. Which caring process is the nurse performing? 5. A nurse is using Watson’s model to provide care to patients. Which carative factor will the nurse use? 6. A nurse provides care that is receptive to patients’ and families’ perceptions of caring. Which action will the nurse take? 7. A nurse follows the “ethics of care” when working with patients. Which action will the nurse take? 8. A nurse is providing presence to a patient and the family. Which nursing action does this involve? 9. The patient is afraid to have a thoracentesis at the bedside. The nurse sits with the patient and asks about the fears. During the procedure, the nurse stays with the patient, explaining each step and providing encouragement. What is the nurse displaying? 10. The patient is terminal and very near death. When the nurse checks the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some family members hold the patient’s hand. The nurse is overwhelmed by the presence of grief and leaves the room. What is the nurse demonstrating? 11. Which action indicates a nurse is using caring touch with a patient? 12. The nurse is caring for a patient who has been sullen and quiet for the past three days. Suddenly, the patient says, “I’m really nervous about surgery tomorrow, but I’m more worried about how it will affect my family.” What should the nurse do first? 13. The patient is about to undergo a certain procedure and has voiced concern about outcomes and prognosis. The nurse caring for the patient underwent a similar procedure and stops to listen. Which response by the nurse may be most beneficial? 14. In making rounds, the nurse meets a patient for the first time. The nurse asks the patient when morning medications are taken, such as before breakfast, after breakfast, or during breakfast. What does knowing the patient allow the nurse to do? MULTIPLE RESPONSE 1. A nurse cares for patients. Which areas does caring influence? (Select all that apply.) 2. Which actions by the nurse should be done in order to get to know the patient? (Select all that apply.) 3. Which actions by the nurse indicate compassion and caring to patients? (Select all that apply.) MATCHING Match the examples to the areas the nurse will promote connectedness for patient’s spirituality needs. a. Connection with others b. Connection with higher power c. Connection with oneself 1. Intrapersonally 2. Interpersonally 3. Transpersonally 1.ANS:CDIF:Understand (comprehension)REF:86 OBJ: Discuss the relationship of compassion to caring. TOP: Caring MSC: Psychosocial Integrity 2.ANS:ADIF:Understand (comprehension)REF:86 OBJ: Discuss the relationship of compassion to caring. TOP: Caring MSC: Psychosocial Integrity 3.ANS:BDIF:Understand (comprehension)REF:86 OBJ: Discuss the relationship of compassion to caring. TOP: Caring MSC: Psychosocial Integrity Chapter 09: Cultural Awareness 1. A nurse is working at a health fair screening people for liver cancer. Which population group should the nurse monitor most closely for liver cancer? 2. A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient? 3. A nurse is assessing the health care disparities among population groups. Which area is the nurse monitoring? 4. A nurse is providing care to a patient from a different culture. Which action by the nurse indicates cultural competence? 5. The nurse learns about cultural issues involved in the patient’s health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating? 6. A nurse is beginning to use patient-centered care and cultural competence to improve nursing care. Which step should the nurse take first? 7. A nurse is performing a cultural assessment using the ETHNIC mnemonic for communication. Which area will the nurse assess for the “H”? 8. The nurse is caring for a patient of Hispanic descent who speaks no English. The nurse is working with an interpreter. Which action should the nurse take? 9. Which action indicates the nurse is meeting a primary goal of cultural competent care for patients? 10. The nurse is caring for a Chinese patient using the Teach-Back technique. Which action by the nurse indicates successful implementation of this technique? 11. A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause the most improvement in core measures? 12. A nurse is designing a form for lesbian, gay, bisexual, and transgender (LGBT) patients. Which design should the nurse use? 13. A nurse is assessing population groups for the risk of suicide requiring medical attention. Which group should the nurse monitor most closely? 14. A nurse is assessing a patient’s ethnohistory. Which question should the nurse ask? 15. A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy? 16. A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital using? 17. A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally congruent care? 18. A nurse is assessing the patient’s meaning of illness. Which area of focus by the nurse ispriority? MULTIPLE RESPONSE 1. A nurse is using Campinha-Bacote’s model of cultural competency. Which areas will the nurse focus on to become competent? (Select all that apply.) 2. A nurse is using the RESPECT mnemonic to establish rapport, the “R” in RESPECT. Which actions should the nurse take? (Select all that apply.) 3. A nurse is using the explanatory model to determine the etiology of an illness. Which questions should the nurse ask? (Select all that apply.) MATCHING A nurse is using Campinha-Bacote’s model of cultural competency to improve cultural care. Which actions describe the components the nurse is using? a. In-depth self-examination of one’s own background b. Ability to assess factors that influence treatment and care c. Sufficient comparative understanding of diverse groups d. Motivation and commitment to continue learning about cultures e. Cross-cultural interaction that develops communication skills 1. Cultural skills 2. Cultural desires 3. Cultural awareness 4. Cultural knowledge 5. Cultural encounters 1.ANS:BDIF:Understand (comprehension)REF:104-105 OBJ: Describe steps toward developing cultural competence. TOP: Assessment MSC:Management of Care 2.ANS DIF:Understand (comprehension)REF:104-105 OBJ: Describe steps toward developing cultural competence. TOP: Assessment MSC:Management of Care 3.ANS:ADIF:Understand (comprehension)REF:104-105 OBJ: Describe steps toward developing cultural competence. TOP: Assessment MSC:Management of Care 4.ANS:CDIF:Understand (comprehension)REF:104-105 OBJ: Describe steps toward developing cultural competence. TOP: Assessment MSC:Management of Care 5.ANS:EDIF:Understand (comprehension)REF:104-105 OBJ: Describe steps toward developing cultural competence. TOP: Assessment MSC:Management of Care Chapter 10: Caring for Families 1. A nurse is assessing the family unit to determine the family’s ability to adapt to the change of a member having surgery. Which area is the nurse monitoring? 2. A nurse reviews the current trends affecting the family. Which trend will the nurse find? 3. A spouse brings the children in to visit their mother in the hospital. The nurse asks how the family is doing. The husband states, “None of her jobs are getting done, and I don’t do those jobs, so the house and the kids are falling apart.” How will the nurse interpret this finding? 4. A nurse cares for the family’s as well as the patient’s needs using available resources. Which approach is the nurse using? 5. A nurse is caring for a patient who needs constant care in the home setting and for whom most of the care is provided by the patient’s family. Which action should the nurse take to help relieve stress? 6. A nurse is working with a patient. When the nurse asks about family members, the patient states that it includes my spouse, children, and aunt and uncle. How will the nurse describe this type of family? 7. A nurse is assessing a child that lives in a car with family members who presents to the emergency department. Which area should the nurse assess closely? 8. The nurse is interviewing a patient who is being admitted to the hospital. The patient’s family went home before the nurse’s interview. The nurse asks the patient, “Who decides when to come to the hospital?” What is the rationale for the nurse’s action? 9. A nurse is caring for a patient from a motor vehicle accident. Which action by the unlicensed assistive personnel will cause the nurse to intervene? 10. A nurse is using the family as context approach to provide care to a patient. What should the nurse do next? 11. The nurse is caring for a patient in hospice. The nurse notes that the patient is getting adequate care, but the spouse is not sleeping well. The nurse also assesses the need for better family nutrition and meals assistance. The nurse discusses these needs with the patient and family and develops a plan of care with them using community resources. Which approach is the nurse using? 12. The nurse is caring for an older adult patient who has no apparent family. When questioned about family and the definition of family, the patient states, “I have no family. They’re all gone.” When asked, “Who prepares your meals?” the patient states, “I do, or I go out.” Which approach should the nurse use for this patient? 13. The nurse is caring for an older adult patient at home who requires teaching for dressing changes. The spouse and adult child are also involved in changing the dressing. Which statement by the nurse will most likely elicit a positive response from the patient and family? 14. The nurse is providing discharge teaching for an older-adult patient who will need tube feedings at home. The spouse is the only source of care and states “I will not be able to perform the feedings due to arthritis.” Which action should the nurse take? MULTIPLE RESPONSE 1. A nurse is assessing threats concerning the family. Which areas will the nurse include in the assessment? (Select all that apply.) 2. A nurse is assessing the realms of family life. Which processes will the nurse assess? (Select all that apply.) MATCHING A nurse is focusing on the interactive processes of family life and is asking the patient questions. Match the questions the nurse will ask to the interactive process. a. Intimacy expression b. Social support c. Roles d. Family nurturing 1. Who is the “peacekeeper” of the family? 2. How are house rules established? 3. How often does the family hug each other? 4. Who at your workplace is close to the family? 1.ANS:CDIF:Analyze (analysis)REF:124 OBJ: Use the nursing process to provide for the health care needs of the family. TOP: Assessment MSC: Psychosocial Integrity Chapter 11: Developmental Theories 1. When caring for a middle-aged adult exhibiting maladaptive coping skills, the nurse is trying to determine the cause of the patient’s behavior. Which information from a growth and development perspective should the nurse consider when planning care? 2. A nurse is measuring an infant’s head circumference and height. Which area is the nurse assessing? 3. Which question will be most appropriate for a nurse to ask when assessing an adult patient for growth and developmental delays? 4. A nurse is using the proximodistal pattern to assess an infant’s growth and development as normal. Which assessment finding will the nurse determine as normal? 5. A nurse is assessing an 18-month-old toddler. The nurse distinguishes normal from abnormal findings by remembering Gesell’s theory of development. Which information will the nurse consider? 6. A nurse is working with a patient who wants needs to be met and is impatient and demanding when these needs are not met immediately. How should the nurse interpret this finding according to Freud? 7. The nurse is teaching a young-adult couple about promoting the health and psychosocial development of their 8-year-old child. Which information from the parent indicates a correct understanding of the teaching? 8. A nurse is using Jean Piaget’s developmental theory to focus on cognitive development. Which area will the nurse assess in this patient? 9. A nurse is assessing a 17-year-old adolescent’s cognitive development. Which behavior indicates the adolescent has reached formal operations? 10. A nurse is caring for a 4-year-old patient. Which object will the nurse allow the child to play with safely to foster cognitive development? 11. A patient follows all the instructions a nurse provides because the patient wants to be perceived as a “good” patient. How should the nurse interpret this information according to moral development? 12. An 18-month-old patient is brought into the clinic for evaluation because the parent is concerned. The 18-month-old child hits siblings and says only “No” when communicating verbally. Which recommendation by the nurse will be best for this situation? 13. A formerly independent older adult becomes severely withdrawn upon admission to a nursing home. Which action should the nurse take first? 14. The nurse is caring for a 14-year-old patient in the hospital. Which goal will be priority? 15. The nurse is teaching the parents of a 3-year-old child who is at risk for developmental delays. Which instruction will the nurse include in the teaching plan? 16. A nurse is caring for a young adult after surgery. Which action by the nurse will be priority? 17. A nurse takes the history of a middle-aged patient in a health clinic. Which information indicates the patient has achieved generativity? 18. Which action should the nurse take when teaching a 5-year-old patient about a scheduled surgery? 19. A nurse works on a pediatric unit and is using a psychosocial developmental approach to child care. In which order from the first to the last will the nurse place the developmental stages? 1. Initiative versus guilt 2. Trust versus mistrust 3. Industry versus inferiority 4. Identity versus role confusion 5. Autonomy versus shame and doubt MULTIPLE RESPONSE 1. A nurse is developing a plan of care concerning growth and development for a hospitalized adolescent. What should the nurse do? (Select all that apply.) a. Apply developmental theories when making observations of the adolescent’s 2. A nurse is assessing temperaments of children. Which terms should the nurse use to describe findings? (Select all that apply.) Chapter 12: Conception Through Adolescence 1. A mother has delivered a healthy newborn. Which action is priority? 2. A nurse teaches a new mother about the associated health risks to the infant. Which statement by the mother indicates a correct understanding of the teaching? 3. A nurse is working in the delivery room. Which action is priority immediately after birth? 4. A nurse is assessing a newborn that was just born. Which newborn finding will cause the nurse to intervene immediately? 5. A nurse performs an assessment on a healthy newborn. Which assessment finding will the nurse document as normal? 6. A nurse is teaching the staff about development. Which information indicates the nurse needs to follow up? 7. A nurse is comparing physical growth patterns between school-aged children and adolescents. Which principle should the nurse consider? 8. The parent brings a child to the clinic for a 12-month well visit. The child weighed 6 pounds 2 ounces and was 21 inches long at birth. Which finding will cause the nurse to intervene? 9. A nurse is assessing the cognitive changes in a preschooler. Which standard will the nurse use to determine normal? 10. The nurse is teaching a parenting class. One of the topics is development. Which statement from a parent indicates more teaching is needed? 11. The nurse is observing a 2-year-old hospitalized patient in the playroom. Which activity will the nurse most likely observe? 12. A nurse is communicating with a newly admitted teenaged patient. Which action should the nurse take? 13. A nurse is caring for a preschooler. Which fear should the nurse most plan to minimize? 14. A nurse is teaching a class about the effects of nutrition on fetal growth and development. A pregnant patient asks the nurse how much weight should normally be gained over the pregnancy. Which information should the nurse share with the patient? 15. The nurse is caring for an infant. Which activity is most appropriate for the nurse to offer to the infant? 16. A mother expresses concern because her 5-year-old child frequently talks about friends who don’t exist. What is the nurse’s best response to this mother’s concern? 17. A school nurse is encouraging children to play a game of kickball. Which group of children is the nurse most likely addressing? 18. Which assessment finding of a school-aged patient should alert the nurse to a possible developmental delay? 19. The nurse is teaching a parent about developmental needs of a 9-month-old infant. Which statement from the parent indicates a correct understanding of the teaching? 20. A nurse is teaching the parents of a school-aged child about accidents most common in this age group. Which topic should the nurse address? 21. Which information from the parent of an 8-month-old infant will cause the nurse to intervene? 22. The nurse is preparing to teach a group of parents with infants about growth and development. Which information should the nurse include in the teaching session? 23. Which statement, if made by a parent, will require further instruction from the nurse? 24. A nurse is teaching parents about appropriate activities for different age groups. Which toy, if selected by the parent of a 12-month-old infant, will indicate a correct understanding of the teaching? MULTIPLE RESPONSE 1. A nurse is teaching a parenting class for families with adolescents. Which health concerns will the nurse include in the teaching session? (Select all that apply.) MATCHING A nurse is teaching parents about the fine motor skills of infants to help parents understand development growth and needs. Match the information to the correct age that the nurse should include in the teaching session. a. Can place objects into containers b. Pulls a string to obtain an object c. Can hold a baby bottle d. Holds rattle for short periods e. Uses pincer grasp well 1. 2 to 4 months 2. 4 to 6 months 3. 6 to 8 months 4. 8 to 10 months 5. 10 to 12 months 1.ANS DIF:Understand (comprehension)REF:145 OBJ: Discuss ways in which the nurse is able to help parents meet their child’s developmental needs. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 2.ANS:CDIF:Understand (comprehension)REF:145 OBJ: Discuss ways in which the nurse is able to help parents meet their child’s developmental needs. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 3.ANS:BDIF:Understand (comprehension)REF:145 OBJ: Discuss ways in which the nurse is able to help parents meet their child’s developmental needs. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 4.ANS:EDIF:Understand (comprehension)REF:145 OBJ: Discuss ways in which the nurse is able to help parents meet their child’s developmental needs. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 5.ANS:ADIF:Understand (comprehension)REF:145 OBJ: Discuss ways in which the nurse is able to help parents meet their child’s developmental needs. TOP: Teaching/Learning MSC: Health Promotion and Maintenance Chapter 13: Young and Middle Adults 1. A nurse is caring for a young adult. Which goal is priority? 2. The nurse is caring for a hospitalized young-adult male who works as a dishwasher at a local restaurant. He states that he would like to get a better job but has no education. How can the nurse best assist this patient psychosocially? 3. Which goal is priority when the nurse is caring for a middle-aged adult? 4. A nurse is teaching young adults about health risks. Which statement from a young adult indicates a correct understanding of the teaching? 5. A nurse is choosing an appropriate topic for a young-adult health fair. Which topic should the nurse include? 6. A nurse is assessing the risk of intimate partner violence (IPV) for patients. Which population should the nurse focus on most for IVP? 7. A patient states that she is pregnant and concerned because she does not know what to expect, and she wants her husband to play an active part in the birthing process. Which information should the nurse share with the patient? 8. Which information from the nurse indicates a correct understanding of emerging adulthood? 9. A nurse is planning care for a 30 year old. Which goal is priority? 10. A nurse is planning care for young-adult patients. Which information should the nurse consider when planning care? 11. During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old female patient reports pain and redness in the right breast. Which action is best for the nurse to take in response to this finding? 12. A 55-year-old female presents to the outpatient clinic describing irregular menstrual periods and hot flashes. Which information should the nurse share with the patient? 13. The nurse is teaching a class to pregnant women about common physiological changes during pregnancy. Which information should the nurse include in the teaching session? 14. A nurse discusses the risks of repeated sun exposure with a young-adult patient. Which response will the nurse most expect from this patient? 15. Upon assessment of a middle-aged adult, the nurse observes uneven weight bearing and decreased range of joint motion. Which area is priority? 16. A young-adult patient is brought to the hospital by police after crashing the car in a high-speed chase when trying to avoid arrest for spousal abuse. Which action should the nurse take? 17. A nurse determines that a middle-aged patient is a typical example of the “sandwich generation.” What did the nurse discover the patient is caught between? MULTIPLE RESPONSE 1. A nurse is assessing a middle-aged patient’s barriers to change in eating habits. Which areas will the nurse assess that are external barriers? (Select all that apply.) 2. A home health nurse is providing care to a middle-aged couple with children at home. The patient has a debilitating chronic illness. Which areas will the nurse need to assess? (Select all that apply.) 3. A nurse is providing prenatal care to a first-time mother. Which information will the nurse share with the patient? (Select all that apply.) MATCHING A nurse is assessing young and middle-aged adults for work-related conditions. Match the job to the work-related conditions that the nurse is assessing. a. Liver disease b. Carpal tunnel syndrome c. Asbestosis d. Farmer’s lung e. Bladder cancer 1. Insulators 2. Dry cleaners 3. Dye workers 4. Office computer workers 5. Agricultural workers 1.ANS:CDIF:Understand (comprehension)REF:164 OBJ: Describe health concerns of the young adult, the childbearing family, and the middle adult. TOP:AssessmentMSC:Health Promotion and Maintenance 2.ANS:ADIF:Understand (comprehension)REF:164 OBJ: Describe health concerns of the young adult, the childbearing family, and the middle adult. TOP:AssessmentMSC:Health Promotion and Maintenance 3.ANS:EDIF:Understand (comprehension)REF:164 OBJ: Describe health concerns of the young adult, the childbearing family, and the middle adult. TOP:AssessmentMSC:Health Promotion and Maintenance 4.ANS:BDIF:Understand (comprehension)REF:164 OBJ: Describe health concerns of the young adult, the childbearing family, and the middle adult. TOP:AssessmentMSC:Health Promotion and Maintenance 5.ANS DIF:Understand (comprehension)REF:164 OBJ: Describe health concerns of the young adult, the childbearing family, and the middle adult. TOP:AssessmentMSC:Health Promotion and Maintenance Chapter 14: Older Adult 1. A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find? 2. A nurse is developing a plan of care for an older adult. Which information will the nurse consider? 3. Which information from a co-worker on a gerontological unit will cause the nurse to intervene? 4. A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse’s suspicions? 5. A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to use? 6. An older patient has fallen and suffered a hip fracture. As a consequence, the patient’s family is concerned about the patient’s ability to care for self, especially during this convalescence. What should the nurse do? 7. What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center? 8. A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. The nurse is discussing health care services and possible long-term living arrangements with the patient’s only son. What will the nurse suggest? 9. A nurse is caring for an older adult. Which goal is priority? 10. A nurse is observing for the universal loss in an older-adult patient. What is the nurse assessing? 11. A nurse is discussing sexuality with an older adult. Which action will the nurse take? 12. A nurse is teaching a health promotion class for older adults. In which order will the nurse list the most common to least common conditions that can lead to death in older adults? 1. Chronic obstructive lung disease 2. Cerebrovascular accidents 3. Heart disease 4. Cancer 13. A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal finding? 14. An older-adult patient in no acute distress reports being less able to taste and smell. What is the nurse’s best response to this information? 15. A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal? 16. An older patient with dementia and confusion is admitted to the nursing unit after hip replacement surgery. Which action will the nurse include in the plan of care? 17. A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will be assisting the patient with which activity? 18. A male older-adult patient expresses concern and anxiety about decreased penile firmness during an erection. What is the nurse’s best response? 19. A patient asks the nurse what the term polypharmacy means. Which information should the nurse share with the patient? 20. An outcome for an older-adult patient living alone is to be free from falls. Which statement indicates the patient correctly understands the teaching on safety concerns? 21. A nurse’s goal for an older adult is to reduce the risk of adverse medication effects. Which action will the nurse take? 22. An older-adult patient has developed acute confusion. The patient has been on tranquilizers for the past week. The patient’s vital signs are normal. What should the nurse do? 23. Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? 24. Which patient statement is the most reliable indicator that an older adult has the correct understanding of health promotion activities? 25. A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public transportation. Which psychosocial change does the nurse focus on as a priority? MULTIPLE RESPONSE 1. A recently widowed older-adult patient is dehydrated and is admitted to the hospital for intravenous fluid replacement. During the evening shift, the patient becomes acutely confused. Which possible reversible causes will the nurse consider when assessing this patient? (Select all that apply.) MATCHING A nurse is using different strategies to meet older patients’ psychosocial needs. Match the strategy the nurse is using to its description. a. Respecting the older adult’s uniqueness b. Improving level of awareness c. Listening to the patient’s past recollections d. Accepting describing of patient’s perspective e. Offering help with grooming and hygiene 1. Body image 2. Validation therapy 3. Therapeutic communication 4. Reality orientation 5. Reminiscence 1.ANS:EDIF:Understand (comprehension)REF:189-190 OBJ: Identify nursing interventions related to the physiological, cognitive, and psychosocial changes of aging. TOP: Implementation MSC: Psychosocial Integrity 2.ANS DIF:Understand (comprehension)REF:189-190 OBJ: Identify nursing interventions related to the physiological, cognitive, and psychosocial changes of aging. TOP: Implementation MSC: Psychosocial Integrity 3.ANS:ADIF:Understand (comprehension)REF:189-190 OBJ: Identify nursing interventions related to the physiological, cognitive, and psychosocial changes of aging. TOP: Implementation MSC: Psychosocial Integrity 4.ANS:BDIF:Understand (comprehension)REF:189-190 OBJ: Identify nursing interventions related to the physiological, cognitive, and psychosocial changes of aging. TOP: Implementation MSC: Psychosocial Integrity 5.ANS:CDIF:Understand (comprehension)REF:189-190 OBJ: Identify nursing interventions related to the physiological, cognitive, and psychosocial changes of aging. TOP: Implementation MSC: Psychosocial Integrity Chapter 15: Critical Thinking in Nursing Practice 1. Which action should the nurse take when using critical thinking to make clinical decisions? 2. Which patient scenario of a surgical patient in pain is most indicative of critical thinking? 3. Which action indicates a registered nurse is being responsible for making clinical decisions? 4. A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene? 5. Which action demonstrates a nurse utilizing reflection to improve clinical decision making? 6. A nursing instructor needs to evaluate students’ abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor’s needs? 7. A nurse is using a critical thinking model to provide care. Which component is first that helps a nurse make clinical decisions? 8. Which action by a nurse indicates application of the critical thinking model to make the bestclinical decisions? 9. A nurse is using the critical thinking skill of evaluation. Which action will the nurse take? 10. The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill? 11. A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? 12. Which action should the nurse take to best develop critical thinking skills? 13. While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take? 14. The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation? 15. A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation? 16. A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility? 17. A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse’s actions? 18. A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following? 19. A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise? 20. In which order will the nurse use the nursing process steps during the clinical decision-making process? 1. Evaluating goals 2. Assessing patient needs 3. Planning priorities of care 4. Determining nursing diagnoses 5. Implementing nursing interventions MULTIPLE RESPONSE 1. Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.) Learn to recognize when you are feeling stressed—your muscles will tense, you become reactive when others communicate with you, you have trouble concentrating, and you feel very tired. Emotions are not managed when stressed. DIF:Understand (comprehension)REF:206 OBJ: Discuss the importance of managing stress when making clinical decisions. TOP:AssessmentMSC:Health Promotion and Maintenance Chapter 16: Nursing Assessment 1. The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? 2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? 3. After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? 4. The nurse is gathering data on a patient. Which data will the nurse report as objective data? 5. A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data? 6. Which method of data collection will the nurse use to establish a patient’s database? 7. A nurse is gathering information about a patient’s habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information? 8. While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do? 9. A nurse has already set the agenda during a patient-centered interview. What will the nurse do next? 10. The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask? 11. A nurse is conducting a nursing health history. Which component will the nurse address? 12. While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take? 13. The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? 14. Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? 15. Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? 16. While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first? 17. A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations? 18. The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview? 19. A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse? MULTIPLE RESPONSE 1. A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.) MATCHING A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using. a. Where is the pain located? b. What causes the pain? c. Does it come and go? d. What does the pain feel like? e. What is the rating on a scale of 0 to 10? 1. Provokes 2. Quality 3. Radiate 4. Severity 5.Time 1.ANS:BDIF:Apply (application)REF:219 OBJ: Describe the methods of data collection. TOP: Assessment MSC: Basic Care and Comfort 2.ANSDIF:Apply (application)REF:219 OBJ: Describe the methods of data collection. TOP: Assessment MSC: Basic Care and Comfort 3.ANS:ADIF:Apply (application)REF:219 OBJ: Describe the methods of data collection. TOP: Assessment MSC: Basic Care and Comfort 4.ANS:EDIF:Apply (application)REF:219 OBJ: Describe the methods of data collection. TOP: Assessment MSC: Basic Care and Comfort 5.ANS:CDIF:Apply (application)REF:219 OBJ: Describe the methods of data collection. TOP: Assessment MSC: Basic Care and Comfort Chapter 17: Nursing Diagnosis 1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions? 2. Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved? 3. A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? 4. The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise? 5. A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing? 6. A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the mostpertinent nursing diagnosis the nurse will include in the plan of care? 7. The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? 8. A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write? 9. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient’s blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? 10. A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain.Which element did the nurse write as the defining characteristic? 11. The patient database reveals that a patient has decreased oral intake, decreased ox