Lecture Exam 2
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Lecture Exam 3 for accelerated nursing program at LCC
- 1.What are the steps of the nursing process?
- A.
Assessment, Outcome Identification, Nursing Diagnosis, Planning, Implementation, Evaluation, Interventions
- B.
Assessment, Nursing Diagnosis, Outcome Identification, Planning, Implementation, Evaluation
- C.
Assessment, Planning, Nursing Diagnosis, Outcome Identification, Implementation, Evaluation
- 2.An actual Nursing Diagnosis has
- A.
Label
- B.
Related factors
- C.
Defining Characteristics
- D.
All the above
- 3.Related factors is
- A.
Signs and symptoms
- B.
Etiology
- 4.Defining characteristics are
- A.
Signs and symptoms
- B.
Subjective and objective
- C.
Etiology
- D.
A and B
- E.
All the above
- 5.Which are priority problems
- A.
Risk for fluid volume deficit
- B.
Fluid volume deficit
- 6.Which are priorities
- A.
Acute pain
- B.
Impaired airway clearance
- 7.The following is a related factor of pain
- A.
C/o sharp discomfort to RLQ of abd
- B.
Tissue trauma from abd surgery
- C.
Tylenol #3 eases pain from 7/10-1/10
- D.
Grimacing when getting out of bed
- 8.The following are defining characteristics of a paralytic ileus except
- A.
Absent bowel sounds
- B.
Felling "bloated"
- C.
Abd distention
- D.
Surgical manipulation of the bowel
- 9.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
- A.
Acute confusion
- B.
Impaired memory
- C.
Risk for acute confusion
- D.
Disturbed thought processes
- 10.Ability to tell me your children's names
- A.
Awareness
- B.
Attention
- C.
Memory
- D.
Learning
- 11.Leaving the IV site & tubing alone because I know it may hurt/ bleed if I pull on it
- A.
Judgment
- B.
Awareness
- C.
Attention
- D.
Orientation
- 12.Pt shows me how they will use the call light after I explained it to them
- A.
Awareness
- B.
Learning
- C.
Memory
- D.
Judgment
- 13.Can tell me their name, where they are, and date
- A.
Awareness
- B.
Orientation
- C.
Memory
- D.
Learning
- 14.Confusion is
- A.
Sign
- B.
Symptom
- C.
Syndrome
- 15.The nursing term is chronic confusion, what is the equivalent medical term
- A.
Dementia
- B.
Delerium
- 16.Vascular dementia occurs more in
- A.
Male
- B.
Female
- 17.Which is not a risk for vascular dementia
- A.
High cholesterol
- B.
Tau tangles
- C.
HTN
- 18.Alzheimer's disease occurs more in
- A.
Male
- B.
Female
- C.
Equal
- 19.I am talking about my dog and get frustrated because I mean to talk about my kids
- A.
Affect
- B.
Aphasia
- C.
Apraxia
- D.
Agnosia
- 20.I can move my legs but I con't figure out how
- A.
Affect
- B.
Aphasia
- C.
Apraxia
- D.
Agnosia
- 21.I don't smile when you smile at me or tell me a funny joke
- A.
Affect
- B.
Aphasia
- C.
Apraxia
- D.
Agnosia
- 22.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?
- A.
Reassess the pt
- B.
Examine the r/t
- C.
Analyze the secondary to factors
- D.
Review the DC
- 23.The nurse performs an assessment of a newly adm pt. The nurse understands that this adm assessment is conducted primarily to:
- A.
Diagnose if the pt is at risk for falls
- B.
Ensure that the pts skin is intact
- C.
Establish a therapeutic relationship
- D.
Identify important data
- 24.The nurse identifies that the patient statement that provides subjective data is:
- A.
"I'm not sure that I am going to be able to manage at home by myself"
- B.
"I can call a home-care agency if I feel I need help at home"
- C.
"What should I do if I have uncontrollable pain at home"
- D.
"Will a home helath aide help me with my care at home"
- 25.The nurse understand that evaluation most directly relates to which aspect of the Nursing Process?
- A.
Goal
- B.
Problem
- C.
Etiology
- D.
Implementation
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