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15 Cards in this Set

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The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process?

A. Assessing
B. Diagnosing
C. Planning
D. Evaluating
Answer: B

Rationale- The nurse identifies human responses to actual or potential health problems during the nursing diagnoses step of the nursing process. During the assessment step, the nurse collects data. During the planning step, the nurse develops strategies to resolve or decrease the patient's problem. During evaluation, the nurse determines the effectiveness of the plan of care.
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the highest priority at this time?

A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion
Answer: D

Rationale: This answer takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis.

Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion
A nurse is revising a client's care plan. During which step of the nursing process does such a revision take place?

A. Assessment
B. Planning
C. Implementation
D. Evaluation
Answer: D

Rationale: During the evaluation step of the nursing process the nurse determines whether the goals established have been achieved, and evaluates the success of the plan. Answer A involves data collection. Answer B involves setting priorities, and Answer C is the actual intervention.
Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?

A. Administer sleeping medication before bedtime
B. Ask the client each morning to describe the quantity of sleep the night before
C. Teach the client relaxation techniques, such as guided imagery and progressive muscle relaxation
D. Provide the client normal sleep aids, such as pillows, back rubs, and snacks
Answer: D

Rationale: You should begin with the simplest interventions. Answer A is incorrect because medications should be avoided whenever possible. Answer B would be a thorough sleep assessment, and should be done only after common sense interventions fail. Answer C would be appropriate only after common sense interventions fail.
A nurse is assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to:

A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex counselor or other appropriate professional
D. Provide support for the spouse
Answer: C

Rationale- Making appropriate referrals is a valid part of planning the client's care. The nurse normally does not provide sex counseling. While providing time for privacy and providing support for the spouse is important, it is not as important as referring the client to a sex counselor/appropriate professional.
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need?

A. Elimination
B. Security
C. Safety
D. Belonging
Answer- A

Rationale - According to Maslow, elimination is a first-level or physiological need. Security and safety are second-level needs, and belonging is a third-level need.
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?

A. Acute pain R/T surgery
B. Deficient fluid volume R/T blood and fluid loss from surgery
C. Impaired physical mobility R/T surgery
D. Risk for aspiration R/T anesthesia
Answer: D

Rationale- Risk for aspiration takes priority because general anesthesia may impair gag and swallow reflexes. The other options, although important, are secondary to this.
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:

A. Assess the client's airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow
Answer: A

Rationale- The first priority is to evaluate airway patency. Pain management and splinting are important for client comfort, but come after an airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.
When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of a patient?

A. Reassess the patient
B. Examine the related to factors
C. Analyze the secondary to factors
D. Review the defining characteristics
Answer: D

Rationale- The first thing a nurse should do to differentiate is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.
The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to:

A. Diagnose if the patient is at risk for falls.
B. Ensure that the patient's skin is intact
C. Establish a therapeutic relationship
D. Identify important data
Answer: D

Rationale- This is the primary purpose of a nursing admission assessment.
The guidelines for writing an appropriate nursing diagnosis include all of the following except:

A. State the diagnosis in terms of a problem, not a need
B. Use nursing terminology to describe the patient's response
C. Use statements that assist in planning independent nursing interventions
D. Use medical terminology to describe the probable cause of the patient's response
Answer- D

Rationale- A nursing diagnosis is a statement about a patient's actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never part of the nursing diagnosis.
Independent nursing interventions commonly used for immobilized patients include all of the following except:

A. Active or passive ROM exercises, body repositioning, and ADLs as tolerated
B. Deep-breathing and coughing exercises with change of position every 2 hours
C. Diaphragmatic and abdominal breathing exercises
D. Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy
Answer: D

Rationale- A, B, & C are incorrect. These are not independent nursing interventions because they require a physician's order.
Independent nursing interventions commonly used for patients with pressure ulcers include:

A. changing the patient's position regularly to minimize pressure
B. Applying a drying agent such as an antacid to decrease moisture at the ulcer site
C. Debriding the ulcer to remove necrotic tissue, which can impede healing
D. Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated
Answer: A

Rationale- Independent nursing interventions for a patient with pressure ulcers commonly include changing positions. B, C, & D all require a physician's order. Additionally, a drying agent (answer B) would be contraindicated because the wound needs moisture to heal.
While the nurse is providing a patient personal hygiene, she observes that his skin is excessively dry. During the procedure, he tells her that he is very thirsty. An appropriate nursing diagnosis would be:

A. Potential for impaired skin integrity R/T altered gland function
B. Potential for impaired skin integrity R/T dehydration
C. Impaired skin integrity R/T dehydration
D. Impaired skin integrity R/T altered circulation
Answer: C

Rationale- The appropriate diagnosis for a patient with excessively dry skin is impaired skin integrity - actual not potential. R/T dehydration is appropriate because the patient complained of thirst.
The most important nursing intervention to correct skin dryness is:

A. avoid bathing until the condition is remedied and notify physician
B. ask physician to refer the patient to a dermatologist
C. Consult the dietitian about increasing fat intake, and take necessary measures to prevent infection
D. encourage the patient to increase fluid intake, use nonirritating soap, and apply lotion to involved areas
Answer: D

Rationale- Preventative measures, such as these, will prevent the skin from cracking, which would make the client more prone to infection. The other 3 answers are options, however NOT the best choice for this particular situation.