Lecture Exam 3
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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.Which concept is related to the ability to focus
- A.
Awareness
- B.
Attention
- C.
Orientation
- D.
Judgment
- 11.Ability to tell me your children's names
- A.
Awareness
- B.
Attention
- C.
Memory
- D.
Learning
- 12.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
- 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 acute confusion, what would the equivalent medical term be
- A.
Dementia
- B.
Delerium
- 16.The nursing term is chronic confusion, what is the equivalent medical term
- A.
Dementia
- B.
Delerium
- 17.An alert and oriented 65yr old pt came into the hospital for a procedure, develped complications with their BP and stayed a few days. On day 3 the RN noticed the pt did not know the date or time, and did not remember them The pt is experiencing
- A.
Delirium
- B.
Dementia
- 18.Vascular dementia occurs more in
- A.
Male
- B.
Female
- 19.Which is not a risk for vascular dementia
- A.
High cholesterol
- B.
Tau tangles
- C.
HTN
- 20.Alzheimer's disease occurs more in
- A.
Male
- B.
Female
- C.
Equal
- 21.What is the only way to 100% Dx alzheimer's disease
- A.
Autopsy
- B.
Check medication
- 22.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
- 23.I can move my legs but I con't figure out how
- A.
Affect
- B.
Aphasia
- C.
Apraxia
- D.
Agnosia
- 24.I don't smile when you smile at me or tell me a funny joke
- A.
Affect
- B.
Aphasia
- C.
Apraxia
- D.
Agnosia
- 25.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
- 26.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
- 27.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"
- 28.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?
- A.
Implementaion
- B.
Assessment
- C.
Evaluation
- D.
Diagnosis
- 29.When the nurse considers the Nursing Process, the word "identify" is to "recognize" as the word "do" is to:
- A.
Plan
- B.
Evaluate
- C.
Diagnose
- D.
Implement
- 30.The nurse is collecting subjective data associated with a pts anxiety. Which assessment method should be used to collect this information?
- A.
Observing
- B.
Inspecting
- C.
Auscultation
- D.
Interviewing
- 31.Which nursing action reflects an activity associated with the diagnosis step of the Nursing Process?
- A.
Formulating a plan of care
- B.
Identifying the pts potential risks
- C.
Designing ways to minimize a pts stressors
- D.
Making decisions about the effectiveness of pt care
- 32.The nurse collects objective data when a hospitalized pt states
- A.
I am hungry
- B.
I feel very warm
- C.
I ate half my lunch
- D.
I have the urge to urinate
- 33.The nurse understands that subjective data has been obtained when the pt states
- A.
I just went to the urinal and it needs to be emptied
- B.
My pain fells like a 5 on a scale of 1 to 5
- C.
The dr said I can go home today
- D.
I only ate half my breakfast
- 34.During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are achieved?
- A.
Implementation
- B.
Evaluation
- C.
Diagnosis
- D.
Planning
- 35.When considering the nursing process the nurse understands that the word observe is to assess as the word determine is to
- A.
Plan
- B.
Analyze
- C.
Diagnose
- D.
Implement
- 36.An essential concept related to understanding the Nursing Process is that it
- A.
Is dynamic rather than static
- B.
Focuses on the role of the nurse
- C.
Moves from the simple to the complex
- D.
Is based on the pts medical problem
- 37.The nurse is caring for a male pt with a urinary elimination problem. Which is the most accurately stated goal? The pt will
- A.
Be taught how to use a urinal when on bed rest
- B.
Experience fewer incontinence episodes at night
- C.
Be assisted to the toilet every two hours and when necessary
- D.
Transfer independently and safely to a commode before discharge
- 38.Which word best describes the role of the nurse when using the Nursing Process to meet the needs of the pt holistically?
- A.
Teacher
- B.
Advocate
- C.
Surrogate
- D.
Counselor
- 39.The nurse understands that the word most closely associated with scientific priniciples is
- A.
Data
- B.
Problem
- C.
Rationale
- D.
Evaluation
- 40.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
- A.
DC
- B.
Outcome criteria
- C.
Etiology
- D.
Goal
- 41.The nurse teaches a pt to use visualization to cope with chronic pain. This action reflects which step of the nursing process
- A.
Planning
- B.
Diagnosis
- C.
Evaluation
- D.
Implementation
- 42.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
- A.
Physicians history and physical
- B.
Social service record
- C.
Admission sheet
- D.
Progress notes
- 43.During which of the five steps in the nursing process does the nurse analyze data critically
- A.
Diagnosis
- B.
Clustering
- C.
Collection
- D.
Assessment
- 44.The nurse is caring for a pt with a fever. Which is a well designed goal for this pt The pt will
- A.
Have a lower temp
- B.
Be give apirin every 8 hours prn
- C.
Be taught how to take an accurate temp
- D.
Maintain fluid intake sufficient to prevent dehydration
- 45.During the evaluation step of the Nursing Process the nurse must
- A.
Establish outcomes
- B.
Determine priorities
- C.
Take corrective action
- D.
Set the time frames for goals
- 46.Determining what nursing actions will be employed occurs in which step of the nursing process
- A.
Implementation
- B.
Assessment
- C.
Diagnosis
- D.
Planning
- 47.The nurse understands that the appropriateness of a nursing diagnosis is supported by its
- A.
DC
- B.
Planned interventions
- C.
Diagnostic statement
- D.
Related risk factors
- 48.The nurse understands that the primary goal of the assessment phase of the nursing process is to
- A.
Build trust and rapport
- B.
Collect and cluster data
- C.
Establish goals and outcomes
- D.
Identify and validate the medical diag
- 49.Which human response identified by the nurse is an example of objective data
- A.
Pain of 5 on a 1 to 1 scale
- B.
Irregular radial pulse of 50 bpm
- C.
Shortness of breath
- D.
Dizziness
- 50.The planning step of the nursing process is influenced most directly by the
- A.
R/t
- B.
Diagnostic label
- C.
Secondary factors
- D.
Medical diagnosis
- 51.The nurse collects data about a pt. Next, the nurse should
- A.
Write a pt centered goal
- B.
Formulate a nursing diag
- C.
Design a plan of nurisng interventions
- D.
Determine the significance of the information
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