Deck 11: Providing Patient-Centered Care Through the Nursing Process

Question 1

Which outcome statement is a properly written goal?

A) "The patient will be free of pain."
B) "The patient will verbalize the importance of lifestyle changes."
C) "The patient will get up into the chair one time daily for 1 hour."
D) "The patient will demonstrate breathing techniques by the end of shift."

Answer 1

C
To be evaluated, an expected outcome must be specific and measurable, meaning that the outcomes can be consistently evaluated. "The patient will get up into the chair one time daily for 1 hour" is specific and measurable. The other outcome statements are vague and open to interpretation. First, being free from pain may mean absolutely no pain or a tolerable level of pain. Second, identifying which lifestyle changes are important to teach the patient may differ from nurse to nurse. Finally, there may be several breathing techniques to teach the patient.

Question 2

The nurse is using Gordon's 11 categories for data collection in performing a health assessment. Which of the following represents assessment of cognition?

A) How educated is the patient?
B) How does the patient describe his or her health?
C) Is the patient well nourished?
D) Has the patient had treatment for emotional problems?

Answer 2

A
Asking the patient's educational level is an assessment of cognition. How the patient describes his or her health is an assessment of health perception and health management. Asking whether the patient is well nourished will assess metabolic pattern, and asking the patient about treatment for emotional problems will assess the patient's pattern of coping and stress tolerance.

Question 3

The nurse reviews assessment findings for assigned patients. Based on this information, which patient demands the nurse's immediate attention? The patient with:

A) renal failure on dialysis whose WBC is 10,000 mm3 (normal)
B) abdominal aneurysm whose blood pressure is 170/90
C) atrial fibrillation whose lab results show and INR of 2.5 (normal)
D) endocarditis who has a loud heart murmur

Answer 3

B
Assessment contains both objective and subjective data. Among other things, the nurse interprets laboratory data to determine whom to see first. The hypertensive patient with an abdominal aneurysm presents the greatest emergency. The patient on dialysis, the patient with A-Fib, and the patient with endocarditis all have normal lab values and clinical findings and present no urgent need for attention.

Question 4

An RN is making assignments on a medical-surgical unit. Which patient could the RN assign to a float RN from the maternity unit?

A) A 68-year-old female patient with COPD and viral pneumonia
B) A 60-year-old female patient with atrial fibrillation and a heart rate of 150
C) A 50-year-old male patient post open heart surgery whose blood pressure is 90/50
D) A 36-year-old male patient who is severely neutropenic awaiting chemotherapy

Question 5

The nurse is attempting to take the history of a newly admitted 92-year-old patient but is unable to obtain the information because of the patient's cognitive status. The nurse should:

A) refuse to complete the admission without more information.
B) contact the family for information on the patient's history.
C) call the doctor in the emergency room for a history.
D) ask another nurse to try to obtain the information from the patient.

Question 6

While the nurse is taking the health history, the patient states, "My father and grandfather both had heart attacks and were unable to be very active afterward." This statement is related to the functional health pattern of:

A) activity-exercise.
B) cognitive-perceptual.
C) health perception-health management.
D) coping-stress tolerance.

Question 7

Which nursing diagnosis would be a priority for a patient in acute respiratory distress?

A) Pain
B) Impaired gas exchange
C) Activity intolerance
D) Deficient knowledge

Question 8

A patient with pneumonia has been using the incentive spirometer four times daily while awake during his 3-day hospitalization. How would the nurse explore the effectiveness of this intervention?

A) The nurse would ask whether the patient was breathing better.
B) The nurse would add turn, cough, and deep breathing exercises.
C) The nurse would watch the patient use the incentive spirometer.
D) The nurse would auscultate the lungs for adventitious breath sounds.

Question 9

Which of the following would be an expected outcome for a patient who is 12 hours status post hip replacement?

A) Increase mobility and decrease pain.
B) Care for the catheter independently.
C) Walk without assistance.
D) Bathe daily in a tub.

Question 10

A patient admitted with a diagnosis of Alzheimer's disease is anxious and dehydrated, has reportedly not been eating, and has had a weight loss of 5 lb in 1 week. Which nursing diagnosis is a priority?

A) Fluid volume deficit related to fluid loss
B) Altered nutrition: Less than body requirements related to anorexia
C) Fluid volume excess related to reduced urine output
D) Risk for impaired skin integrity

Question 11

The nurse is planning care for an 82-year-old obese female patient with Alzheimer's dementia. The patient wanders, is unsteady on her feet, and is visually impaired. What should the nurse give priority to when developing the plan of care?

A) Laboratory results
B) Skin condition
C) Safety
D) Nutrition

Question 12

The nurse is admitting a 64-year-old Hispanic male patient to the rehabilitation facility following surgical intervention for a broken hip. The nurse should first assess which of the following?

A) Self-care ability
B) Self-esteem
C) Communication
D) Pain

Question 13

Which statement by the nurse illustrates how a nursing patient assessment differs from a medical patient assessment?

A) "The patient is able to stand for 30 seconds before walking 10 feet toward the bathroom without an assistive device."
B) "The patient is fearful that he will not be discharged home after his hospitalization."
C) "The patient stated he felt pain in his lower back after slipping on his icy driveway."
D) "The patient experienced a persistent cough, and azithromycin was prescribed 6 weeks ago. Today, she presents with a recurrent cough, green sputum, and worsening shortness of breath."

Question 14

An RN team leader has one LPN and one medical assistant assigned to the unit. Which patient would be most appropriate to assign to the LPN?

A) Right lower lobectomy, one day postoperatively, whose temperature went from 37.1°C to 38.3°C during the last shift
B) 72-year-old right hip replacement, 2 days postoperatively, complaining of leg and chest pain
C) 48-year-old female patient who had a laparoscopic appendectomy 8 hours ago: urine output 165 mL, Hgb 7 g/dL, and Hct 21%
D) Post cerebral vascular accident 1 week ago who had a Dobhoff feeding tube inserted and is now on continuous feedings at 45 mL/hr

Question 15

The nurse is charting on the patient who is status post surgery for an abdominal abscess and notes: "Pt's temperature has not exceeded 37°C this shift." This is an example of a(n):

A) intervention.
B) outcome.
C) plan.
D) diagnosis or analysis.

Question 16

Which of the following is an example of a measurable outcome for the patient who has undergone a surgical procedure with a pain rating of 7 on a scale of 0 to 10?

A) The patient's pain will be under control by Sunday.
B) The patient will have no pain by the end of this shift.
C) The patient's pain will decrease by the end of shift on (date).
D) The patient's pain will decrease to 2 or lower by the end of shift on (date).

Question 17

Which of the following would be a priority nursing diagnosis for a 73-year-old male patient with heart failure?

A) Constipation related to immobility
B) Risk for infection related to IV lines
C) Activity intolerance related to an imbalance of oxygen and demand
D) Self-care deficit

Question 18

Determine which example is true of measurability within the context of the nursing diagnosis.

A) The patient will list signs of infection such as redness, pain, swelling, and warmth by the end of the shift.
B) The patient will be pain-free and then walk to the bathroom.
C) The patient reported abdominal pain for 2 days but denies nausea, vomiting, and diarrhea.
D) The patient received Dilaudid 1 mg IV and 2 hours later received Lortab 500/5.

Question 19

Which of these strategies should be a priority when the nurse is planning care for a patient with hypertension?

A) Obtain less expensive antihypertensive medications.
B) Assist with dietary changes as the first action.
C) Follow evidence-based guidelines for appropriate interventions.
D) Teach about the impact of exercise on hypertension.

Question 20

The nurse is planning care for a patient with hypertension and obesity. Which of the following is a reasonable and measurable outcome for the nursing diagnosis of noncompliance with treatment regimen related to side effects of medications?

A) The patient will state two lifestyle modifications for weight management by (date certain).
B) The patient will be compliant with the treatment regimen by (date certain).
C) The patient will understand the disease process by (date certain).
D) The patient's blood pressure will never increase.

Question 21

In the assessment phase of the nursing process, there are several ways to collect data. Which statements reflect the need for more training? (Select all that apply.)

A) "The patient is talking in full sentences with visitors and appears to be breathing without distress."
B) "Bowel sounds are hypoactive in all four quadrants; no pain with palpation."
C) "Mrs. Collins, are you experiencing any pain right now?"
D) "According to the chart, the patient slept well last night as a result of the pain medicine administered at 2100."
E) "The abdominal wound is slightly red at the approximated edges, no edema noted."

Question 22

Errors may occur with the use of data in formulating an appropriate nursing diagnosis. Based on what you know, which of the following represents the main source of errors in the nursing diagnosis process?

A) Making assumptions without supporting data
B) Placing data in incorrect categories
C) Not validating data with the patient
D) Relying on team members for data

Question 23

An example of an intervention independently initiated by the nurse is:

A) starting a teaching plan for the patient who will go home tomorrow.
B) instituting diet restrictions with subsequent progression of diet as tolerated.
C) sending an abnormal appearing urine sample to the lab for routine urinalysis.
D) writing an order for aspirin for a headache.

Question 24

A nursing intervention directs the patient to be turned every 2 hours to prevent skin breakdown from immobility. Assessment findings on new reddened areas on the lateral aspects of the right knee and ankle are obtained. What is the most appropriate way for these findings to be used when the care plan is evaluated?

A) The information will be added to the relevant area of the electronic medical record.
B) The nursing diagnosis will be changed from an actual problem to a potential problem.
C) The new intervention of calling the physician will be added to the care plan.
D) The intervention will change to have the patient turned every hour.

Question 25

Which of the following is true about collaborative problems?

A) Collaborative problems fall within the definition of nursing diagnoses.
B) Collaborative problems are managed using two physicians.
C) Collaborative problems require the nurse to monitor for changes in status.
D) Collaborative problems emphasize prevention, treatment, or health promotion.