FUNDAMENTALS OF NURSING CARE PRACTICE QUESTIONS AND ANSWERS

FUNDAMENTALS OF NURSING CARE PRACTICE QUESTIONS AND ANSWERS Assume you are scheduled for clinical tomorrow. How would you obtain information about your patient so that you can begin to develop a plan of care? a. Read the nursing admissions assessment and recent nurse's notes. b. Read the health-care provider's admission note and recent progress notes. c. Listen to the end-of-shift report at the nurse's station. d. Review the medication administration record and any treatment plans or notes. - CORRECT ANSWER-All of the above Objective data - CORRECT ANSWER-Data that can be assessed through the senses Primary data - CORRECT ANSWER-Data provided by the patient Secondary data - CORRECT ANSWER-Data obtained from a source other than the patient Subjective data - CORRECT ANSWER-Symptoms knowable only by the patient Care plan - CORRECT ANSWER-A documented strategy that includes the health-care provider's orders, nursing diagnoses, and nursing orders is called the _____ Critical thinking - CORRECT ANSWER-_____ is using competent reasoning and logical thought processes to determine the merits of a belief or action Validate - CORRECT ANSWER-To avoid making decisions based on assumptions, nurses _______ the information they obtain. Nursing process - CORRECT ANSWER-The ______ is an overlapping, five-step method for decision making. Rapport - CORRECT ANSWER-Creating a relationship of mutual trust is called establishing a ______. Nursing diagnosis - CORRECT ANSWER-The concise statement of a problem that the patient is experiencing as a result of his or her medical diagnoses is called the _______. Defining characteristics - CORRECT ANSWER-The signs and symptoms experienced by the patient that directly influence the nursing diagnosis are called the ________. Expected outcome - CORRECT ANSWER-The ______ is the overall direction that will indicate improvement in a problem. Nursing goals - CORRECT ANSWER-______ are statements of measurable action for the patient within a specific time frame in response to nursing interventions. Direct patient care - CORRECT ANSWER-When an individual nurse performs hands-on or one-on-one nursing interventions, it is called ______. Indirect patient care - CORRECT ANSWER-Activities that a nurse performs that do not involve hands-on or one-on-one patient care but nonetheless have an impact on the patient are called ______. Independent interventions - CORRECT ANSWER-Actions the nurse performs that do not require a written order are called _______. Dependent interventions - CORRECT ANSWER-Actions the nurse performs that require a written order are called ______. Collaborate interventions - CORRECT ANSWER-Nursing actions that involve working with other disciplines such as physical therapy or social services are called. Refer to the Real-World Connection feature called Critical Thinking in Patient Care located in Chapter 4 in your textbook. What did the nurse and the therapist do that is a characteristic feature of critical thinking? a. They made important observations b. They made a difference in patient care c. They thought they could get to the bottom of the problem d. They made a conscious decision to think in a new way about the problem. - CORRECT ANSWER-d. They made a conscious decision to think in a new way about the problem. You are accepting a patient who is being transferred to your general care unit after 3 days in the intensive care unit (ICU) following a stroke. Many of the stroke symptoms have resolved, and the patient needs only minimal physical and occupational therapy. Because the care in uncomplicated and you are busy with patients who are sicker, you ask the unlicensed assistant to develop the care plan, after which you will assess it and revise it as needed. Which of the following statements about your actions is true? a. This is fine; you may delegate care planning as long as a licensed nurse reviews it. b. This is fine as long as you choose the nursing diagnosis. c. This is not allowed because nursing decisions and care planning cannot be delegated. d. This is not allowed because the patient is coming from an ICU. - CORRECT ANSWER-c. This is not allowed because nursing decisions and care planning cannot be delegated. Your patient was admitted to the hospital with severe abdominal pain. It was determined that he had pancreatitis as a result of severely elevated triglycerides. He was also diagnosed with type 2 diabetes, and you plan to teach him about his diagnosis. He is not allowed anything by mouth yet because of the pancreatitis, is receiving IV fluids, and requires pain medication every 3 to 4 hours. You enter the room and let him know you want to discuss his health conditions with him. He responds by saying, "Not now, please, I just got my pain shot." Which of the following explains how the patient's comment reflects Maslow's hierarchy of needs? a. He has to have his safety and security needs met before he can address cognitive needs. b. Cognitive needs are less important than physical needs. c. He cannot deal with learning new issues while he feels physically uncomfortable. d. His discomfort is preventing him from cooperating. - CORRECT ANSWER-c. He cannot deal with learning new issues while he feels physically uncomfortable. A student in your class is given the name of a patient for whom she will proved care the following day in clinical. She goes to the unit, which specializes in diabetes care, to find out information and sees the patient sitting in a wheelchair with his chart in his lap. He is on his way to radiology for an x-ray. She notes that his left leg is amputated just below the knee and the right foot s bandaged . Your class has been studying diabetes and the student knows that vascular problems and amputations are unfortunate complications of diabetes. She plans to study about the diabetic foot care tonight so that she will be prepared for clinical the next day. Which of the following represents an accurate statement about her decision to study diabetic foot care? a. It reflects careful observation and good planning. b. The amputation and bandage are pretty obvious, so her plan is just common sense. c. She should read the patient's specific foot care program before reading about general diabetic foot care. d. She has made a serious thinking error. - CORRECT ANSWER-d. She has made a serious thinking error. Which step of the nursing process is concerned with identifying physical findings? a. Assessment b. Diagnosis c. Planning d. Implementation e. Evaluation - CORRECT ANSWER-a. Assessment In which step of the nursing process would you look at outcomes? a. Assessment b. Diagnosis c. Planning d. Implementation e. Evalutation - CORRECT ANSWER-e. Evaluation In which step of the nursing process are priorities set? a