Lecture Exam 2
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Which are priorities
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Acute pain
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Impaired airway clearance
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Lecture Exam 3 for accelerated nursing program at LCC
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- 2.
The nursing term is chronic confusion, what is the equivalent medical term
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Dementia
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Delerium
Correct Answer
A. Dementia -
- 3.
During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are achieved?
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Implementation
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Evaluation
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Diagnosis
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Planning
Correct Answer
A. Evaluation -
- 4.
Pt shows me how they will use the call light after I explained it to them
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Awareness
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Learning
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Memory
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Judgment
Correct Answer
A. Learning -
- 5.
Ability to tell me your children's names
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Awareness
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Attention
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Memory
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Learning
Correct Answer
A. Memory -
- 6.
An actual Nursing Diagnosis has
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Label
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Related factors
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Defining Characteristics
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All the above
Correct Answer
A. All the above -
- 7.
I don't smile when you smile at me or tell me a funny joke
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Affect
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Aphasia
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Apraxia
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Agnosia
Correct Answer
A. Affect -
- 8.
The nurse teaches a pt to use visualization to cope with chronic pain. This action reflects which step of the nursing process
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Planning
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Diagnosis
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Evaluation
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Implementation
Correct Answer
A. Implementation -
- 9.
Which are priority problems
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Risk for fluid volume deficit
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Fluid volume deficit
Correct Answer
A. Fluid volume deficit -
- 10.
Can tell me their name, where they are, and date
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Awareness
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Orientation
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Memory
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Learning
Correct Answer
A. Orientation -
- 11.
The nurse performs an assessment of a newly adm pt. The nurse understands that this adm assessment is conducted primarily to:
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Diagnose if the pt is at risk for falls
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Ensure that the pts skin is intact
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Establish a therapeutic relationship
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Identify important data
Correct Answer
A. Identify important data -
- 12.
What are the steps of the nursing process?
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Assessment, Outcome Identification, Nursing Diagnosis, Planning, Implementation, Evaluation, Interventions
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Assessment, Nursing Diagnosis, Outcome Identification, Planning, Implementation, Evaluation
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Assessment, Planning, Nursing Diagnosis, Outcome Identification, Implementation, Evaluation
Correct Answer
A. Assessment, Nursing Diagnosis, Outcome Identification, Planning, Implementation, Evaluation -
- 13.
The nurse understands that subjective data has been obtained when the pt states
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I just went to the urinal and it needs to be emptied
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My pain fells like a 5 on a scale of 1 to 5
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The dr said I can go home today
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I only ate half my breakfast
Correct Answer
A. My pain fells like a 5 on a scale of 1 to 5 -
- 14.
The nurse is collecting subjective data associated with a pts anxiety. Which assessment method should be used to collect this information?
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Observing
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Inspecting
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Auscultation
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Interviewing
Correct Answer
A. Interviewing -
- 15.
Vascular dementia occurs more in
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Male
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Female
Correct Answer
A. Male -
- 16.
The nurse identifies that the patient statement that provides subjective data is:
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"I'm not sure that I am going to be able to manage at home by myself"
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"I can call a home-care agency if I feel I need help at home"
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"What should I do if I have uncontrollable pain at home"
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"Will a home helath aide help me with my care at home"
Correct Answer
A. "I'm not sure that I am going to be able to manage at home by myself" -
- 17.
The nurse understand that evaluation most directly relates to which aspect of the Nursing Process?
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Goal
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Problem
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Etiology
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Implementation
Correct Answer
A. Goal -
- 18.
When the nurse considers the Nursing Process, the word "identify" is to "recognize" as the word "do" is to:
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Plan
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Evaluate
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Diagnose
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Implement
Correct Answer
A. Implement -
- 19.
Which word best describes the role of the nurse when using the Nursing Process to meet the needs of the pt holistically?
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Teacher
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Advocate
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Surrogate
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Counselor
Correct Answer
A. Advocate -
- 20.
Which human response identified by the nurse is an example of objective data
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Pain of 5 on a 1 to 1 scale
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Irregular radial pulse of 50 bpm
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Shortness of breath
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Dizziness
Correct Answer
A. Irregular radial pulse of 50 bpm -
- 21.
A pt has multiple diagnostic tests performed. Where in the pts chart can the nurse find documentation about the current medical diagnosis after the diagnostic test results are reported
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Physicians history and physical
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Social service record
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Admission sheet
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Progress notes
Correct Answer
A. Progress notes -
- 22.
Determining what nursing actions will be employed occurs in which step of the nursing process
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Implementation
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Assessment
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Diagnosis
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Planning
Correct Answer
A. Planning -
- 23.
Which nursing action reflects an activity associated with the diagnosis step of the Nursing Process?
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Formulating a plan of care
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Identifying the pts potential risks
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Designing ways to minimize a pts stressors
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Making decisions about the effectiveness of pt care
Correct Answer
A. Identifying the pts potential risks -
- 24.
Which is not a risk for vascular dementia
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High cholesterol
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Tau tangles
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HTN
Correct Answer
A. Tau tangles -
- 25.
I can move my legs but I con't figure out how
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Affect
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Aphasia
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Apraxia
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Agnosia
Correct Answer
A. Apraxia -
- 26.
The following are defining characteristics of a paralytic ileus except
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Absent bowel sounds
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Felling "bloated"
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Abd distention
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Surgical manipulation of the bowel
Correct Answer
A. Surgical manipulation of the bowel -
- 27.
Defining characteristics are
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Signs and symptoms
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Subjective and objective
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Etiology
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A and B
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All the above
Correct Answer
A. A and B -
- 28.
The following is a related factor of pain
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C/o sharp discomfort to RLQ of abd
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Tissue trauma from abd surgery
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Tylenol #3 eases pain from 7/10-1/10
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Grimacing when getting out of bed
Correct Answer
A. Tissue trauma from abd surgery -
- 29.
The nurse collects objective data when a hospitalized pt states
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I am hungry
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I feel very warm
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I ate half my lunch
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I have the urge to urinate
Correct Answer
A. I ate half my lunch -
- 30.
An essential concept related to understanding the Nursing Process is that it
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Is dynamic rather than static
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Focuses on the role of the nurse
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Moves from the simple to the complex
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Is based on the pts medical problem
Correct Answer
A. Is dynamic rather than static -
- 31.
During which of the five steps in the nursing process does the nurse analyze data critically
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Diagnosis
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Clustering
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Collection
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Assessment
Correct Answer
A. Diagnosis -
- 32.
Your 8- yr old pt is very forgetful, does not know where they are and say's they are 50 years old. all of the following are possible NANDA labels for this pt except
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Acute confusion
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Impaired memory
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Risk for acute confusion
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Disturbed thought processes
Correct Answer
A. Risk for acute confusion -
- 33.
The nurse understands that the word most closely associated with scientific priniciples is
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Data
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Problem
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Rationale
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Evaluation
Correct Answer
A. Rationale -
- 34.
A pebble dropped into a pond causes ripples on the surface of the water. Which part of the nursing diagnosis is most directly related to this concept
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DC
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Outcome criteria
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Etiology
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Goal
Correct Answer
A. Etiology -
- 35.
Related factors is
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Signs and symptoms
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Etiology
Correct Answer
A. Etiology -
- 36.
Leaving the IV site & tubing alone because I know it may hurt/ bleed if I pull on it
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Judgment
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Awareness
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Attention
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Orientation
Correct Answer
A. Judgment -
- 37.
The nurse is caring for a pt with a fever. Which is a well designed goal for this pt The pt will
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Have a lower temp
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Be give apirin every 8 hours prn
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Be taught how to take an accurate temp
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Maintain fluid intake sufficient to prevent dehydration
Correct Answer
A. Maintain fluid intake sufficient to prevent dehydration -
- 38.
I am talking about my dog and get frustrated because I mean to talk about my kids
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Affect
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Aphasia
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Apraxia
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Agnosia
Correct Answer
A. Aphasia -
- 39.
When considering the nursing process the nurse understands that the word observe is to assess as the word determine is to
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Plan
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Analyze
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Diagnose
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Implement
Correct Answer
A. Diagnose -
- 40.
Alzheimer's disease occurs more in
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Male
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Female
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Equal
Correct Answer
A. Equal -
- 41.
The nurse comes to the conclusion that a pts elevated temperature, pulse, and respiration are significant. What step of the Nursing Process is being used when the nurse comes to this conclusion?
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Implementaion
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Assessment
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Evaluation
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Diagnosis
Correct Answer
A. Diagnosis -
- 42.
During the evaluation step of the Nursing Process the nurse must
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Establish outcomes
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Determine priorities
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Take corrective action
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Set the time frames for goals
Correct Answer
A. Take corrective action -
- 43.
The planning step of the nursing process is influenced most directly by the
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R/t
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Diagnostic label
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Secondary factors
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Medical diagnosis
Correct Answer
A. R/t -
- 44.
The nurse understands that the appropriateness of a nursing diagnosis is supported by its
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DC
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Planned interventions
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Diagnostic statement
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Related risk factors
Correct Answer
A. DC -
- 45.
When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of the pt?
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Reassess the pt
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Examine the r/t
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Analyze the secondary to factors
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Review the DC
Correct Answer
A. Review the DC -
- 46.
Confusion is
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Sign
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Symptom
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Syndrome
Correct Answer
A. SyndromeExplanation
a collection of S & SxRate this question:
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- 47.
The nurse collects data about a pt. Next, the nurse should
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Write a pt centered goal
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Formulate a nursing diag
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Design a plan of nurisng interventions
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Determine the significance of the information
Correct Answer
A. Determine the significance of the information -
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Current Version
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Dec 13, 2012Quiz Edited by
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Oct 20, 2008Quiz Created by
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