Lecture Exam 2

1. Which are priorities

Acute pain

Impaired airway clearance

2. The nursing term is chronic confusion, what is the equivalent medical term

Dementia

Delerium

3. During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are achieved?

Implementation

Evaluation

Diagnosis

Planning

4. Pt shows me how they will use the call light after I explained it to them

Awareness

Learning

Memory

Judgment

5. Ability to tell me your children's names

Awareness

Attention

Memory

Learning

6. An actual Nursing Diagnosis has

Label

Related factors

Defining Characteristics

All the above

7. I don't smile when you smile at me or tell me a funny joke

Affect

Aphasia

Apraxia

Agnosia

8. The nurse teaches a pt to use visualization to cope with chronic pain. This action reflects which step of the nursing process

Planning

Diagnosis

Evaluation

Implementation

9. Which are priority problems

Risk for fluid volume deficit

Fluid volume deficit

10. Can tell me their name, where they are, and date

Awareness

Orientation

Memory

Learning

11. The nurse performs an assessment of a newly adm pt. The nurse understands that this adm assessment is conducted primarily to:

Diagnose if the pt is at risk for falls

Ensure that the pts skin is intact

Establish a therapeutic relationship

Identify important data

12. What are the steps of the nursing process?

Assessment, Outcome Identification, Nursing Diagnosis, Planning, Implementation, Evaluation, Interventions

Assessment, Nursing Diagnosis, Outcome Identification, Planning, Implementation, Evaluation

Assessment, Planning, Nursing Diagnosis, Outcome Identification, Implementation, Evaluation

13. The nurse understands that subjective data has been obtained when the pt states

I just went to the urinal and it needs to be emptied

My pain fells like a 5 on a scale of 1 to 5

The dr said I can go home today

I only ate half my breakfast

14. The nurse is collecting subjective data associated with a pts anxiety. Which assessment method should be used to collect this information?

Observing

Inspecting

Auscultation

Interviewing

15. Vascular dementia occurs more in

Male

Female

16. The nurse identifies that the patient statement that provides subjective data is:

"I'm not sure that I am going to be able to manage at home by myself"

"I can call a home-care agency if I feel I need help at home"

"What should I do if I have uncontrollable pain at home"

"Will a home helath aide help me with my care at home"

17. The nurse understand that evaluation most directly relates to which aspect of the Nursing Process?

Goal

Problem

Etiology

Implementation

18. When the nurse considers the Nursing Process, the word "identify" is to "recognize" as the word "do" is to:

Plan

Evaluate

Diagnose

Implement

19. Which word best describes the role of the nurse when using the Nursing Process to meet the needs of the pt holistically?

Teacher

Advocate

Surrogate

Counselor

20. Which human response identified by the nurse is an example of objective data

Pain of 5 on a 1 to 1 scale

Irregular radial pulse of 50 bpm

Shortness of breath

Dizziness

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

Physicians history and physical

Social service record

Admission sheet

Progress notes

22. Determining what nursing actions will be employed occurs in which step of the nursing process

Implementation

Assessment

Diagnosis

Planning

23. Which nursing action reflects an activity associated with the diagnosis step of the Nursing Process?

Formulating a plan of care

Identifying the pts potential risks

Designing ways to minimize a pts stressors

Making decisions about the effectiveness of pt care

24. Which is not a risk for vascular dementia

High cholesterol

Tau tangles

HTN

25. I can move my legs but I con't figure out how

Affect

Aphasia

Apraxia

Agnosia

26. The following are defining characteristics of a paralytic ileus except

Absent bowel sounds

Felling "bloated"

Abd distention

Surgical manipulation of the bowel

27. Defining characteristics are

Signs and symptoms

Subjective and objective

Etiology

A and B

All the above

28. The following is a related factor of pain

C/o sharp discomfort to RLQ of abd

Tissue trauma from abd surgery

Tylenol #3 eases pain from 7/10-1/10

Grimacing when getting out of bed

29. The nurse collects objective data when a hospitalized pt states

I am hungry

I feel very warm

I ate half my lunch

I have the urge to urinate

30. An essential concept related to understanding the Nursing Process is that it

Is dynamic rather than static

Focuses on the role of the nurse

Moves from the simple to the complex

Is based on the pts medical problem

31. During which of the five steps in the nursing process does the nurse analyze data critically

Diagnosis

Clustering

Collection

Assessment

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

Acute confusion

Impaired memory

Risk for acute confusion

Disturbed thought processes

33. The nurse understands that the word most closely associated with scientific priniciples is

Data

Problem

Rationale

Evaluation

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

DC

Outcome criteria

Etiology

Goal

35. Related factors is

Signs and symptoms

Etiology

36. Leaving the IV site & tubing alone because I know it may hurt/ bleed if I pull on it

Judgment

Awareness

Attention

Orientation

37. The nurse is caring for a pt with a fever. Which is a well designed goal for this pt The pt will

Have a lower temp

Be give apirin every 8 hours prn

Be taught how to take an accurate temp

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

Affect

Aphasia

Apraxia

Agnosia

39. When considering the nursing process the nurse understands that the word observe is to assess as the word determine is to

Plan

Analyze

Diagnose

Implement

40. Alzheimer's disease occurs more in

Male

Female

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?

Implementaion

Assessment

Evaluation

Diagnosis

42. During the evaluation step of the Nursing Process the nurse must

Establish outcomes

Determine priorities

Take corrective action

Set the time frames for goals

43. The planning step of the nursing process is influenced most directly by the

R/t

Diagnostic label

Secondary factors

Medical diagnosis

44. The nurse understands that the appropriateness of a nursing diagnosis is supported by its

DC

Planned interventions

Diagnostic statement

Related risk factors

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?

Reassess the pt

Examine the r/t

Analyze the secondary to factors

Review the DC