Nursing Process

82問 • 3年前

問題一覧

The nurse identifies the nursing process as the foundation of professional nursing practice and can define it in which appropriate terms?

The framework that nurses use to provide care

The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The nurse knows which essential step was added in 1991?

Outcome identification

Since the nursing process is cyclic rather than linear, the nurse knows that as an individual patient's condition changes the nurse should anticipate what concept?

The accuracy and effectiveness of thought processes must be considered.

The charge nurse is discussing a patient's care plan during a team meeting. The team determines that the patient has not met the goal of "ambulating to the nurse's station twice a day" and decides to revise the plan. The nurse recognizes which characteristic of the nursing process most represents this decision?

Outcome oriented

The nurse is caring for a patient who will be discharged home following surgical repair of a broken shoulder. The patient tells the nurse, "I don't have anyone at home who can help me cook my meals. Is there something you can do?" When demonstrating the adaptability of the nursing process, the nurse should carry out which task?

Contact the social worker about community services.

The community health nurse is applying the nursing process to the care of patients with coronary artery disease. The nurse determines that most of the patients eat high-fat meals from local fast-food restaurants and plans a nutrition workshop. The nurse is applying which characteristic of the nursing process?

Adaptability

The nursing student is caring for a patient admitted with severe anemia. The patient receives two units of packed red blood cells and tells the student, "I am feeling so much better. I'm not so tired anymore and can bathe myself." The student reviews the patient goal "report an increase in activity tolerance" and concludes that the patient's goal has been met and adjusts the patient's plan of care. The nurse knows this is applying which characteristic of the nursing process?

Dynamics

The nurse is completing the health history on a patient admitted for cardiac rehabilitation. The nurse recognizes that the health history is conducted in which step of the nursing process?

Assessment

The nurse is assisting a patient to bed when the patient says, "My chest hurts and my left arm feels numb. What's wrong with me?" What is the type and source of data obtained from the patient's complaint?

Subjective data from a primary source

A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process?

Assessment

While the nurse is assisting with morning care, the patient has a tonic clonic seizure. The nurse immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of the nursing process?

Implementation

The nurse is caring for a patient diagnosed with Lyme disease. The patient tells the nurse, "My heart seems to be skipping some beats. My doctor told me to let the nurse know if this happens since it might be a complication of my disease." The nurse auscultates the heart and confirms the palpitations. Which step of the nursing process does the nurse's action demonstrate?

Assessment

In which step of the nursing process does the nurse prioritize the nursing diagnoses and identify interventions to address the patient goals?

Planning

The nurse writes a short-term goal for a patient scheduled for surgery in the morning and identifies which goal that contains all the necessary elements?

The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery.

A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. When the nurse asks the manager if there is a document written by the physician for this type of reaction, the nurse is referring to which concept?

Standing order

All nursing interventions that are implemented for patients must be documented or charted. The nurse knows that proper documentation of interventions leads to what positive outcome?

Proper documentation facilitates communication with all members of the health care team.

The nurse makes the following entry on the patient's care plan: "Goal not met. Patient refuses to walk and states, 'I'm afraid of falling." The nurse should complete which next action?

Modify the care plan in response to the patient's condition and wishes.

The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a patient scheduled for back surgery. Which step of the nursing process is the nurse addressing?

Implementation

The nurse develops a list of nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, "I understand that I will lose most of my hair. Will it grow back?" The nurse identifies which diagnosis will have the highest priority?

Disturbed body image

The nurse is gathering data on a patient with acute bacterial pneumonia. The nurse recognizes that this is an example of which step of the nursing process?

Assessment

The nurse is caring for a patient with pneumonia, who is a retired soldier who served in World War II. With this information in mind, what should the nurse do in regarding this patient?

Shake the patient's hand and allow the patient time to "warm up."

The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient. During the orientation phase of a patient interview, the nurse carries out what action?

Establish the name by which the patient prefers to be addressed.

A nurse is conducting a health interview on a newly admitted patient. To establish a trusting relationship with the patient, the nurse carries out which action?

Sit close and leans in slightly toward the patient.

The nurse is assigned the admission health history and physical for a patient diagnosed with a fever of unknown etiology. The patient tells the nurse, "I just don't feel good. I'm so hot and I feel sick to my stomach. Can you ask me those questions later?" What would be the best response by the nurse?

Let me see if you can have something for the nausea and then talk later."

The nurse is using a stethoscope to assess a patient's cardiac status. Which assessment technique is the nurse using?

Auscultation

The nurse is performing an assessment of a patient's right kidney. The nurse bluntly strikes the area of the costovertebral angle while observing the patient's reaction. Which assessment technique is the nurse using?

Percussion

The nurse is performing a physical exam on a patient diagnosed with liver failure resulting from chronic alcoholism. The nurse notes that the abdomen is swollen and decides to assess for abdominal skin tenderness and temperature. Which technique would the nurse use to collect this data?

Palpation

The triage nurse in a hospital emergency department is determining the order of care for several patients. Which patient would the nurse consider as having the highest priority?

A 14-year-old patient having respiratory distress and increasing anxiety

The morning nurse is assigned to care for a patient admitted during the night with rectal bleeding. When making rounds, the nurse observes that the patient's face is ashen in color and the skin is cool and clammy. The nurse auscultates the patient's heart and lungs. Which category of physical assessment is the basis for the nurse's response?

Emergency assessment

The nurse is performing her initial assessment of the day when she notices that the patient has a facial droop that was not present yesterday and that was not reported in the hand-off report from the night nurse. The nurse proceeds to assess the neurologic status of the patient and knows this to be which type of assessment?

Focused assessment

The nurse is documenting data collected during a health assessment interview. Which statement by the nurse indicates subjective data?

"My last bowel movement was 4 days ago."

A patient is transported to the emergency department from a local skilled nursing facility and admitted for a bacterial blood infection. The nurse reviews the transferring physician notes, which indicate that the patient has dementia. The nurse contacts the patient's son for additional health history information. Information provided by the son would be considered which type of data?

Secondary, subjective data

The nurse is monitoring the blood sugar results of a patient receiving an intravenous nutritional supplement. The patient tells the nurse, "I have never had sugar problems before. My doctor says it is because I am getting this IV." These types of data are considered to be which type?

Primary, subjective data

The unlicensed nursing assistive person (UP) reports to the nurse that a patient is crying during a comedy show on television. What would be the best response by the nurse?

"I will go visit her right away and see what is going on."

A patient with moderate lower back pain tells the nurse, "My urine smells awful and is as dark as my glass of tea." Which action by the nurse will assist in validating the patient's concern?

Review the lab results of the most recent urinalysis.

The nurse is attempting to get the patient to sign the operative consent. When asked if the health care provider explained the procedure to the patient, the patient replies "Not much." What action will the nurse take next?

Ask the patient what information the surgeon has explained about the surgery.

After the patient's data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. What is the framework that provides the most holistic view of the patient's condition?

Functional Health Patterns

The wound care nurse is assessing a non-healing leg wound on a patient recently admitted for uncontrolled diabetes. The nurse organizes the data using which Gordon's Functional Health Pattern?

Nutrition and metabolism

During the health history interview, the patient tells the nurse, "Just walking to the mailbox and back makes my calves ache. Is this normal?" Which framework would the nurse most likely choose to document this data?

Body systems model

The nurse completes a health and physical assessment on a patient admitted with a fractured pelvis. Which task would the nurse do next?

Analyze and cluster the assessment information.

A group of patients in a community center attend a nursing-led information session on the risks of contracting tuberculosis. After the presentation, several patients ask the nurse for additional web-based resources regarding the lung disease. Which type of nursing diagnosis would the nurse choose for the community care plan?

Health promotion

A nurse completes a care plan for an assigned patient diagnosed with an inflammation of the pericardium. Which diagnosis written on the plan indicates a need for further instruction on using the nursing process?

Pericarditis

A patient is receiving an experimental drug for leukemia. The nurse is worried that the drug mav cause a reduction in platelets leading to intestinal tract bleeding. Which type of nursing diagnosis does the nurse use to address this concern?

Risk

The nurse is writing the care plan for a patient admitted to the hospital for complications associated with muscular dystrophy. Which nursing diagnosis written on the care plan indicates a need for further instruction in constructing the diagnostic statement?

Impaired airway clearance related to muscle weakness

Nursing students are analyzing the following nursing diagnostic statement during a study group session. Acute pain related to pressure on lumbar spinal nerves as evidenced by a pain level of 9, patient verbalizations of pain, and grimacing when walking. The students would be correct if they stated which response to be the etiology of the patient's problem?

Pressure on lumbar spinal nerves

The nurse is caring for a patient diagnosed with blood clots in the right lower extremity. The admitting provider orders bed rest. The patient tells the nurse, "I usually exercise three times a week. It helps me go to the bathroom." The nurse determines that the patient may have difficulty with bowel movements. Which nursing diagnosis statement accurately reflects the nurse's concern?

Risk for constipation related to insufficient physical activity

The nursing student is reviewing the components of a nursing diagnosis. Which statement made by the student indicates correct understanding of a health-promotion diagnostic statement?

"The defining characteristics will include the patient's willingness to get better.

The nurse is reviewing assessment findings on a patient admitted with an extremely slow heart rate in preparation to write a care plan. The patient complains of dizziness, shortness of breath, chest pain, and fainting spells. Vital signs are blood pressure of 98/60 mm Hg and pulse of 52 beats/min. Oxygen saturation is 88%. Which action does the nurse perform next?

Evaluate the data looking for patterns and related data.

The nurse is admitting a patient with severe dehydration. Assessment data reveal a decreased blood pressure, an increased pulse rate, and a low circulating blood volume. The student observes that the patient is confused and restless. Which patient information would the nurse consider as a contributing factor when choosing the nursing diagnostic label?

Blood pressure, pulse rate, blood volume, mental status, dehydration

The nurse is reviewing data obtained through the health history interview and physical assessment of an assigned patient. Data collected include dry skin, brittle nails, weight gain, thinning hair, constipation, prolonged menstruation, and the patient's complaints of feeling tired and cold. The nurse recognizes which statement represents an appropriate data cluster?

Constipation, weight gain

The nurse in an outpatient clinic obtains a blood pressure of 190/88 mm Hg on a patient diagnosed with high blood pressure. The patient tells the nurse, "My blood pressure medicine is really expensive. Do you think I really need it?' The nurse assumes the patient is not taking the medication based on the blood pressure result and the patient's statement and chooses lack of knowledge as a diagnostic label. The nurse identifies the action taken is an example of what concept of nursing diagnosis formation?

Clustering unrelated data in the diagnostic statement.

The nurse is developing a plan of care for a patient with gastritis and an inflammation of the intestines. The patient is complaining of severe abdominal discomfort and nausea. The patient also reports having restless leg syndrome and an inability to urinate. What should the nurse write as a problem statement for the nursing diagnosis?

Abdominal pain and nausea related to inflammation

The nursing student submits a care plan to the nursing instructor for a review prior to implementing the nursing interventions. The instructor identifies which nursing diagnostic statement that is written incorrectly?

impaired sleep and lack of knowledge related to stress as evidenced by patient report of difficulty sleeping and lack of energy.

When creating a nursing diagnosis, the nurse knows the related factor is based on what premise?

It is the underlying etiology of the patient's situation.

The nurse is caring for a complex patient needing physical and emotional support. As the primary caregiver, the nurse has which responsibility?

The nurse is ultimately responsible for assessment of patient needs and progress.

The nurse has identified several problems for a patient scheduled for a bone marrow transplant. When formulating the nursing diagnosis, the nurse includes which key concept?

The nurse facilitates communication of patient needs and promotes accountability.

The nurse is developing a plan of care for a patient who had a stroke. Assessment findings include weakness in right upper and lower extremities, numbness in face, slurred speech, difficulty with walking and balance, and headache. The nurse identifies which response would best represent the etiology of the patient's gait and balance problems?

Lack of muscle motor movement

The nurse is caring for a patient admitted to the intensive care unit with malnutrition. The patient is unable to walk and has developed a pressure ulcer from lying in bed constantly without changing positions. The family believes that the patient is depressed and that is why getting out of bed has stopped. When planning this patient's care, the nurse will include which key concept!

Develop multiple nursing diagnoses.

The nurse is caring for a patient who has undergone abdominal surgery. The patient stated prior to surgery that "I don't think I'll be able to handle this if I get a colostomy. I wouldn't know how to manage it." The patient is complaining of severe surgical pain and has an order for morphine sulfate. The nurse is correct when addressing which nursing diagnosis first?

Pain

Setting priorities among identified nursing diagnoses is the first step in the planning process. The nurse knows this prioritization includes which action?

Monitoring patient responses

Which assessment made by the nurse should be addressed first?

Shortness of breath

Which patient issue should the nurse address first?

Absence of pulse

The nurse demonstrates a thorough understanding of the planning phase of the nursing process when making which statement?

"Patients should be included in the planning process."

The nurse recognizes that patient goals include which characteristic?

They are mutually acceptable to the nurse, patient, and family.

When developing the nursing care plan, the nurse includes which concept when creating goals?

Creates the goals with the patient and possibly the family

Which statement by the nurse is correct regarding diversity considerations?

High numbers of minority populations do not understand health teachings

The nurse recognizes which is a correctly written example of a short-term goal?

The patient will eat 75% of all meals for the next 3 days.

The nurse identifies which goal is written correctly for the nursing diagnosis of activity intolerance related to imbalance between oxygen supply and demand?

Patient will ambulate 100 feet with no shortness of breath on third day after treatment.

The nurse recognizes which response as a barrier to achieving goals?

The effects of pain and/or clinical depression

The nurse is caring for a patient who has had abdominal surgery and has developed a slight temperature. The nurse identifies which statement to be a patient-centered goal?

The patient will ambulate 10 feet by postoperative day 2.

The nurse knows which response to be an example of a measurable goal?

"The patient will be able to lift 10 lb by the end of week one."

The nurse is formulating the patient's care plan. In determining when to evaluate the patient's progress, the nurse is aware that evaluations should be carried out within which parameters?

They depend on intervention and patient condition.

The nurse knows that standardized care plans may be available and are utilized under which circumstance?

They need to be individualized for each patient.

The nurse recognizes which term identifies nursing interventions that originate from the health care provider orders?

Dependent

The nurse identifies medication administration to be what type of nursing intervention?

Dependent

The nurse recognizes which action to be a dependent nursing intervention?

Oxygen administration via mask

The nurse recognizes that physical therapy, speech therapy, home health care, and personal care are examples of which type of interventions?

Collaborative interventions

The nurse understands that discharge planning begins at what point in the patient's hospitalization?

Upon admission

The nurse identifies which statement to be accurate regarding discharge planning?

“It may decrease the incidence of patients who need to return to the hospital."

The nurse identifies which action as a direct-care intervention?

Administration of an injection

The nurse manager is creating the patient assignment for today. She has five registered nurses (RNs), two licensed practical nurses (LPs), and five nurse technicians (NAs) scheduled. When making the assignment, the nurse manager needs to remember which fact of delegation?

RNs are responsible for all care delegated to unlicensed nursing personnel.

The nurse is preparing to administer medications to a patient. When the patient reports new shortness of breath, which action by the nurse is most appropriate?

Check the provider orders for all forms of prescription medications.

NUR 170 exam 4

V Farris · 50問 · 2年前

NUR 170 exam 4