Lecture Exam 3

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. Ability to tell me your children's names

Awareness

Attention

Memory

Learning

5. An actual Nursing Diagnosis has

Label

Related factors

Defining Characteristics

All the above

6. Which are priority problems

Risk for fluid volume deficit

Fluid volume deficit

7. 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

Delirium

Dementia

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. 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

10. What is the only way to 100% Dx alzheimer's disease

Autopsy

Check medication

11. 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

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

Affect

Aphasia

Apraxia

Agnosia

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

Awareness

Orientation

Memory

Learning

14. Which concept is related to the ability to focus

Awareness

Attention

Orientation

Judgment

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

Plan

Evaluate

Diagnose

Implement

16. 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

17. 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

18. 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

19. Vascular dementia occurs more in

Male

Female

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. The nursing term is acute confusion, what would the equivalent medical term be

Dementia

Delerium

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

Implementation

Assessment

Diagnosis

Planning

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

Absent bowel sounds

Felling "bloated"

Abd distention

Surgical manipulation of the bowel

24. Which is not a risk for vascular dementia

High cholesterol

Tau tangles

HTN

25. The nurse understands that the primary goal of the assessment phase of the nursing process is to

Build trust and rapport

Collect and cluster data

Establish goals and outcomes

Identify and validate the medical diag

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

Affect

Aphasia

Apraxia

Agnosia

27. Defining characteristics are

Signs and symptoms

Subjective and objective

Etiology

A and B

All the above

28. Related factors is

Signs and symptoms

Etiology

29. 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"

30. 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

31. 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

32. 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

33. 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

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

Judgment

Awareness

Attention

Orientation

35. 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

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

Data

Problem

Rationale

Evaluation

37. I am talking about my dog and get frustrated because I mean to talk about my kids

Affect

Aphasia

Apraxia

Agnosia

38. 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

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. 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

41. 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

42. Alzheimer's disease occurs more in

Male

Female

Equal

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

Diagnosis

Clustering

Collection

Assessment

44. 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

45. The nurse is caring for a male pt with a urinary elimination problem. Which is the most accurately stated goal? The pt will

Be taught how to use a urinal when on bed rest

Experience fewer incontinence episodes at night

Be assisted to the toilet every two hours and when necessary

Transfer independently and safely to a commode before discharge

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

R/t

Diagnostic label

Secondary factors

Medical diagnosis

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

Establish outcomes

Determine priorities

Take corrective action

Set the time frames for goals

48. Confusion is

Sign

Symptom

Syndrome

a collection of S & Sx

Explanation

a collection of S & Sx

49. 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