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NUR3632 Foundations Exam 2 Study
1. A nurse is planning care for a male adolescent patient who is admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. The nurse formulates nursing diagnoses. The nurse identifies expected patient outcomes. The nurse selects evidence-based nursing interventions. The nurse explains the nursing care plan to the patient. The nurse assesses the patient's mental status. The nurse evaluates the patient's outcome achievement.: b, c, d. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and com- municate the plan of nursing care. Although all these steps may overlap, formulating and validating nursing diagnoses occurs most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process. 2. A nurse on a busy surgical unit relies on informal planning to provide appro- priate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. A nurse sits down with a patient and prioritizes existing diagnoses.
A nurse assesses a woman for postpartum depression during routine care. A nurse plans interventions for a patient who is diagnosed with epilepsy. A busy nurse takes time to speak to a patient who received bad news. A nurse reassesses a patient whose PRN pain medication is not working. A nurse coordinates the home care of a patient being discharged.: b, d, e. Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.
3. 3. When helping a patient turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. This is an example of what type of planning? Initial planning Standardized planning Ongoing planning
belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.
5.. A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. The nurse uses a binary decision tree for stepwise assessment and interven- tion. The nurse is able to measure the cause-and-effect relationship between path- way and patient outcomes. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice.
The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. The nurse uses a decision tree that provides intense specificity and no provider flexibility.: a, c. A critical pathway represents a sequential, interdisci- plinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and in- tervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.
6. A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. An example of an affective outcome for this patient is: Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. By 6/12/15, the patient will correctly demonstrate application of wet-to- dry dressing on leg ulcer. By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 33 to 2.53). By 6/12/15, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.: d. Affective
(b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.
8. A nurse is caring for an elderly male patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? Offer the patient 60 mL fluid every 2 hours while awake. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. Teach the patient the importance of drinking enough fluids to prevent dehy- dration by 1/15/ At the next visit, 12/23/15, the patient will know that he should drink at least 3 liters of water per day.: b. The outcomes in a and c make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60 mL fluid every 2 hours while awake." Correct: "The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/15." The outcome in d makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." 9. A nurse is collecting more patient data to confirm a diagnosis of em- physema for a 68-year-old male patient. What type of diagnosis does this intervention seek to confirm? Actual Possible
Risk Collaborative: b. An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions.
10. A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement below is not an example of a well-stated nursing intervention? Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake.
analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.
12. A nurse is caring for an older adult patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. Bronchial pneumonia Impaired gas exchange Ineffective airway clearance Potential complication: sepsis Infection related to pneumonia Risk for septic shock: b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.
13. After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self- esteem? No problem Possible problem Actual nursing diagnosis Clinical problem other than nursing diagnosis: b. When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem. 14. A nurse assesses a patient and formulates the following nursing diagno- sis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? Risk for Impaired Skin Integrity Related to prescribed bedrest As evidenced by As evidenced by reddened areas of skin on the heels and back:
professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.
16. To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to: Compare this reading to standards. Check the taxonomy of nursing diagnoses for a pertinent label. Check a medical text for the signs and symptoms of high blood pressure. Consult with colleagues.: a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis. 17. When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." Which of the following comments is the nurse most likely to hear from the instructor? "Hold on a minute... Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue." "Job well done... you've identified this problem early and we can manage it before it becomes more acute." "Is this an actual or a possible diagnosis?" "This is a medical, not a nursing problem.": a. A data cluster is a grouping
of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. There may be a reason for the lack of a bowel movement for 2 days, or it might be this individual's normal pattern.
18. A nurse makes a clinical judgment that an African American male patient in a stressful job is more vulnerable to developing hypertension than White male patients in the same or similar situation. The nurse has formulated what type of nursing diagnosis? Actual Risk Possible Wellness: b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis. 19. A nurse is writing nursing diagnoses for patients in a psychiatrist's of- fice. Which nursing diagnoses are correctly written as two-part nursing diag- noses? (1) Ineffective Coping related to inability to maintain marriage (2) Defensive Coping related to loss of job and economic security (3) Altered Thought Processes related to panic state (4) Decisional Conflict related to placement of parent in a long-term care facility (1) and (2)
facilitate coping as evidenced by caregiver's loss of weight and clinical depression (1) and (3) (2) and (4) (1), (2), and (3) All of the above: b. (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement.
21. A school nurse notices that a female adolescent student is losing weight and decides to perform a focused assessment of her nutritional status to determine if she has an eating disorder. How should the nurse proceed? Perform the focused assessment. This is an independent nurse-initiated inter- vention. Request an order from Jill's physician since this is a physician-initiated inter- vention. Request an order from Jill's physician since this is a collaborative interven- tion. Request an order from the nutritionist since this is a collaborative inter- vention.: a. Performing a focused assessment is an independent nurse- initiated intervention, thus the nurse does not need an order from the physician or the nutritionist. 22. A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best repre- sent this step? Select all that apply.
The nurse carefully removes the bandages from a burn victim's arm. The nurse assesses a patient to check nutritional status. The nurse formulates a nursing diagnosis for a patient with epilepsy. The nurse turns a patient in bed every 2 hours to prevent pressure ulcers. The nurse checks a patient's insurance coverage at the initial interview. The nurse checks for community resources for a patient with dementia.: a, d, f. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.
23. Nurses use the Nursing Interventions Classification Taxonomy structure as a resource when planning nursing care for patients. What information would be found in this structure? Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention A complete list of reimbursable charges for each nursing intervention: b. The Nursing Interventions Classification Taxonomy lists nursing
A nurse records the I&O of a patient as prescribed by his physician. A nurse prepares a patient for minor surgery according to facility protocol.: c, d, f. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician. Consulting with a psychiatrist is a collaborative intervention.
26. A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the first nursing action that should be taken prior to performing this care? Administer pain medication. Reassess the patient. Prepare the equipment. Explain the procedure to the patient.: b. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and if necessary administer pain medications. 27. A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident with the procedure. What would be the
student's best response? Tell the RN that he or she lacks the technical competencies to change the dressing independently. Assemble the equipment for the procedure and follow the steps in the proce- dure manual. Ask another student nurse to work collaboratively with him or her to change the dressing. Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.: a. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the plan of care. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.
28. A nurse develops a detailed plan of care for a 16-year-old female who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? "You know your personal situation better than I do, so I will respect your wishes." "If you don't accept these services, your baby's health will suffer." "Let's take a look at the plan again and see if we can adjust it to fit your needs." "I'm going to assign your case to a social worker who can explain the services better.": c. When a patient does not follow the plan of care
