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21 Cards in this Set

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After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: A. Encourage client to implement guided imagery when pain begins. B. Determine effect of pain intensity on client function. C. Administer analgesic 30 minutes before physical therapy treatment. D. Pain intensity reported as a 3 or less during hospital stay.
D
When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: A. Apply a cold pack to the tibia. B. Elevate the leg 5 inches above the heart. C. Perform range of motion to right leg every 4 hours. D. Administer aspirin 325 mg every 4 hours as needed
B
Which of the following nursing interventions are written correctly? (Select all that apply.) A. Apply continuous passive motion machine during day. B. Perform neurovascular checks. C. Elevate head of bed 30 degrees before meals. D. Change dressing once a shift.
C
A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers: A. Notifying the physician B. Calling the wound care nurse C. Changing the wound care treatment D. Consulting with another nurse
B
When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: A. Length of time current treatment has been in place. B. The spouse’s reaction to the client’s dressing change C. Client’s concern about the current treatment D. Physician’s reluctance to change the current treatment plan
A
The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to: A. Implement the specialist’s recommendations B. Report the recommendations to the primary physician C. Clarify the suggestions with the client and family members D. Discuss and review advised strategies with CNS
D
Nursing interventions for a specific problem developed in the hospital setting do not require a _______________, but this aspect is important for the nursing student in order to reinforce the importance of evidence-based nursing practice.
RATIONALE
After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. 1. Constipation 2. Anticipatory grieving 3. Ineffective airway clearance 4. Ineffective tissue perfusion
3,4,1,2
During the planning phase of the nursing process, the nurse along with the client decides the following (select all that apply): A. Nursing diagnosis B. Client-centered goals C. Nurse-centered priorities D. Interventions E. Expected outcomes
b, e. These are the main components of the planning phase of the nursing process., a. The nurse determines these from the assessment. c. The client should be the focus of the planning stage. d. Interventions are initially determined by the nurse.
A client with a spinal cord injury was admitted today to a rehabilitation institution. The rehabilitation nurse develops long-term goals that focus on four aspects of care. Those four aspects are:
1. Prevention (of complications) 2. Rehabilitation (return to maximum function) 3. Discharge (returning to the community) 4. Health education (knowledge regarding maintaining wellness based on age and gender)
ONCE A NURSE ASSESSES A CLIENT’S CONDITION AND IDENTIFIES APPROPRIATE NURSING DIAGNOSES A: A. PLAN IS DEVELOPED FOR NURSING CARE B. PHYSICAL ASSESSMENT BEGINS C. LIST OF PRIORITIES IS DETERMINED D. REVIEW OF THE ASSESSMENT IS CONDUCTED WITH OTHER TEAM MEMBER
A. PLAN OS DEVELOPED FOR NURSING CARE
PLANNING IS A CATEGORY OF NURSING BEHAVIORS IN WHICH - A. THE NURSE DETERMINES THE HEALTH CARE NEEDED FOR THE CLIENT B. THE PHYSICIAN DETERMINES THE PLAN OF CARE FOR THE CLIENT C. CLIENT-CENTERED GOALS AND EXPECTED OUTCOMES ARE ESTABLISHED D. THE CLIENT DETERMINES THE CARE NEEDED
C. CLIENT-CENTERED GOALS AND OUTCOMES ARE ESTABLISHED
PRIORITIES ARE ESTABLISHED TO HELP THE NURSE ANTICIPATE AND SEQUENCE NURSING INTERVENTIONS WHEN A CLIENT HAS MULTIPLE PROBLEMS OR ALTERATIONS. PRIORITIES ARE DETERMINED BY THE CLIENT’S: A. PHYSICIAN B. NON-EMERGENT NON LIFE THREATENING NEEDS C. FUTURE WELL BEING D. URGENCY OF PROBLEMS
D. URGENCY OF PROBLEMS
A CLIENT CENTERED GOAL IS A SPECIFIC AND MEASURABLE BEHAVIOR OR RESPONSE THAT REFLECTS A CLIENTS - A. DESIRE FOR SPECIFIED HEALTH CARE INTERVENTIONS B. HIGHEST POSSIBLE LEVEL OF WELLNESS AND INDEPENDENCE IN FUNCTION C. PHYSICIANS GOAL FOR THE SPECIFIC CLIENT D. RESPONSE WHEN COMPARED TO ANOTHER CLIENT WITH A LIKE PROBLEM
B. HIGHEST POSSIBLE LEVEL OF WELLNESS AND INDEPENDENCE IN FUNCTION
FOR CLIENTS TO PARTICIPATE IN GOAL SETTING THEY SHOULD BE - A. ALERT AND HAVE SOME DEGREE OF INDEPENDENCE B. AMBULATORY AND MOBILE C. ABLE TO SPEAK AND WRITE D. ABLE TO READ AND WRITE
A. ALERT AND HAVE SOME DEGREE OF INDEPENDENCE
THE NURSE WRITES AN EXPECTED OUTCOME STATEMENT IN MEASURABLE TERMS. AN EXAMPLE IS: - A. CLIENT WILL HAVE LESS PAIN B. CLIENT WILL BE PAIN FREE C. CLIENT WILL REPORT PAIN ACTIVITY LESS THAN 4 ON A SCALE OF 0-10 D. CLIENT WILL TAKE PAIN MEDICATION EVERY 4 HOURS
C. CLIENT WILL REPORT PAIN ACTIVITY LESS THAN 4 ON A SCALE OF 0-10
AS GOALS OUTCOMES AND INTERVENTIONS ARE DEVELOPED THE NURSE MUST: A. BE IN CHARGE AND PLANNING OF ALL CARE FOR THE CLIENT B. BE AWARE OF AND COMMITTED TO ACCEPTED STANDARDS OR PRACTICE FROM NURSING AND OTHER DISCIPLINES C. NOT CHANGE THE PLAN OF CARE FOR THE CLIENT D. BE IN CONTROL OF ALL INTERVENTIONS FOR THE CLIENT
BE AWARE OF AND COMMITTED TO ACCEPTED STANDARDS OF PRACTICE FROM NURSING AND OTHER DISCIPLINES
WHEN ESTABLISHING REALISTIC GOALS THE NURSE: A. BASES THE GOALS ON THE NURSE'S PERSONAL KNOWLEDGE B. KNOWS THE RESOURCES OF THE HEALTH CARE FACILITY FAMILY, AND CLIENT C. MUST HAVE A CLIENT WHO IS PHYSICALLY AND EMOTIONALLY STABLE D. MUST HAVE THE CLIENTS COOPERATION
B. KNOWS THE RESOURCES OF THE HEALTH CARE FACILITY FAMILY AND CLIENT
TO INITIATE AN INTERVENTION THE NURSE MUST BE COMPETENT IN THREE AREAS WHICH INCLUDE: A. KNOWLEDGE, FUNCTION, AND SPECIFIC SKILLS B. EXPERIENCE, ADVANCED EDUCATION AND SKILLS, C. SKILLS, FINANCES, AND LEADERSHIP D. LEADERSHIP, AUTONOMY AND SKILLS
A. KNOWLEDGE FUNCTION AND SPECIFIC SKILLS
COLLABORATIVE INTERVENTIONS ARE THERAPIES THAT REQUIRE: A. PHYSICIAN AND NURSE INTERVENTION B. NURSE AND CLIENT INTERVENTION C. CLIENT AND PHYSICIAN INTERVENTION D. MULTIPLE HEALTH CARE PROFESSIONALS
D. MULTIPLE HEALTH CARE PROFESSIONALS