Lecture Exam 3

51 Questions | Total Attempts: 333

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Lecture Quizzes & Trivia

Lecture Exam 3 for accelerated nursing program at LCC


Questions and Answers
  • 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