Question 1

Ms.Dionne,56,has been having abdominal pain without any clear pathology for cause.The x-rays are normal,and there had been no recent trauma.Which of the following is the most appropriately written nursing diagnosis for this client?

Accepted Answer

Option B accurately describes the situation by stating that the pain is related to an unknown etiology. Option A is too vague and does not provide enough information about the cause of the pain. Option C assumes that the pain is caused by a psychosomatic condition, which may not be the case. Option D is redundant as the fact that the client is experiencing pain is already established.

Question 2

A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits.The most appropriate diagnosis for this client is which of the following?

Accepted Answer

A wellness diagnosis focuses on the promotion of health and prevention of illness. This is the most appropriate diagnosis for a client seeking information and education regarding healthy lifestyles and eating habits as it is aimed at maintaining and improving their overall well-being.

Question 3

What is a useful technique for clustering data?

Accepted Answer

Concept mapping is a useful technique for clustering data. It involves organizing information into visual representations using concept maps, which allows for easier identification of patterns and relationships within the data. Critical pathways, inferencing, and priority setting are not specific techniques for clustering data.

Question 4

Hannah,17,is quiet,pale,diaphoretic,and restless in her hospital bed.As the nurse is gathering data,Hannah says,"just leave me alone." Which of the following is subjective data?

Accepted Answer

"Just leave me alone" is a statement made by Hannah and is therefore subjective data. The other options are objective data that can be observed by the nurse.

Question 5

A client with a non-life-threatening wound to his hand comes into a very busy and crowded emergency department.What is the best way for the nurse to conduct an interview with this client?

Accepted Answer

The best way to conduct an interview with a client in a busy and crowded emergency department is to draw curtains around the client and nurse to provide as much privacy as possible. This will allow the nurse to ask sensitive questions and collect important information without being overheard by others in the department. It also helps to maintain the client's dignity and confidentiality. Waiting until the department quiets down or conducting the interview in the waiting room may result in delays in care and compromise the quality of nursing care. Ensuring that the client's back is to the rest of the room is not sufficient to ensure privacy and confidentiality.

Question 6

A nurse makes the decision to look at wound care alternatives for Mr.Cutcliffe,87,who has a stasis ulcer that has not improved over the past two weeks.This represents which phase of the nursing process?

Accepted Answer

The nurse is evaluating the effectiveness of the current wound care plan and considering alternatives because the ulcer has not improved, which is part of the evaluation phase.

Question 7

A nurse is providing a back rub to a client immediately after administering a pain medication,with the hope that these two actions will help decrease the client's pain.This is an example of which phase of the nursing process?

Accepted Answer

Providing a back rub is a nursing intervention, which falls under the implementation phase. The nurse has already assessed the client's pain and given medication, and evaluation of the effectiveness of the interventions will come later. A diagnosis is not needed in this situation as the client's pain was already identified and treated.

Question 8

A nursing diagnosis of fluid volume deficit,related to active fluid loss,secondary to diarrhea has been formulated for a client.An appropriately written goal statement for this diagnosis would be which of the following?

Accepted Answer

A goal statement should be specific, measurable, achievable, relevant, and time-bound (SMART). Option D meets these criteria as it is specific (1000 mL intake), measurable (can be tracked over 24 hours), achievable (not too difficult to achieve), relevant (addresses fluid volume deficit), and time-bound (within 24 hours). Options A, B, and C are not specific enough and do not provide measurable criteria or a time frame for achievement.

Question 9

What type of data,also known as signs,are detectable by an observer?

Accepted Answer

Objective data, also known as signs, can be observed and measured. They are measurable and quantifiable. Examples of objective data include vital signs, laboratory results, and physical examination findings. Subjective data, on the other hand, are based on personal opinions, feelings, and experiences, and therefore cannot be observed or measured. Variable data refers to data that can change from time to time, while constant data is data that remains the same over time.

Question 10

Neena,15 months,has been admitted to the pediatric unit.Her parents are worried and upset,and her grandmother is also present.In this situation,what/who would be the best source of data?

Accepted Answer

Neena's parents are the best source of data despite their emotional state, as they are most likely to have the most accurate and comprehensive information about Neena's health history and current condition.

Question 11

A nursing student does not understand the difference between evaluation and assessment.In order to differentiate between the two,what should the student remember?

Accepted Answer

Evaluation is the process of analyzing and interpreting data gathered during assessment in order to make decisions about the effectiveness of a program or intervention. Assessment, on the other hand, is the process of gathering data or information about a particular situation or individual, often at the beginning of a process. Therefore, the primary difference between the two is in how the data collected are used.

Question 12

While setting up for a procedure,an operating room nurse notices that the client has become unresponsive and respirations have become shallow.What type of assessment would be necessary in this situation?

Accepted Answer

In this situation, an emergency assessment is necessary to quickly assess the client's status and determine the appropriate actions to take. Immediate interventions may be necessary to support the client's breathing and potentially save their life.

Question 13

Mr.Vallente,32,was admitted just prior to the shift change.The oncoming nurse asks him many of the same questions as did the previous nurse.Mr.Vallente asks,"Why don't you people quit asking the same things over and over?" Which one of the following is the best response by the nurse?

Accepted Answer

The answer of Mr.Vallente,32,was admitted just prior to the shift...

Question 14

A student nurse understands that clustering data comes with experience and recognizing cues.What is the best way to recognize patterns or cues in the data?

Accepted Answer

The answer of A student nurse understands that clustering data...

Question 15

A client has been admitted for acute dehydration,secondary to nausea and diarrhea.When is the best time for the nurse to conduct this client's interview?

Accepted Answer

It is best to wait until the client has been oriented to the room and their physical symptoms have been addressed before conducting an interview. This allows the client to feel more comfortable and focused, which can lead to a more accurate and thorough assessment. Conducting the interview after medication may also be an option, but it is important to ensure that the client is fully awake and alert before proceeding. Family availability may be helpful, but it should not be the primary factor in determining when to conduct the interview.

Question 16

A client has been seeing a nurse practitioner for counselling following a rape.A long-term goal for this client would be which of the following?

Accepted Answer

Returning to the level of purpose and functioning as before the rape is a long-term goal that requires significant progress in the healing process. It indicates that the client has achieved a sense of recovery and regained their ability to function in their daily life without being significantly impacted by the trauma. The other options are important goals in the healing process but they are not necessarily indicators of achieving a full recovery.

Question 17

A goal statement in a client's care plan states: Client will have clear lung sounds bilaterally within three days.One of the interventions is to teach the client to cough and deep breathe every 2 hours.By the third day,the client's lungs are clear.To relate the intervention to the outcome,what should the nurse do?

Accepted Answer

The answer of A goal statement in a client's care...

Question 18

Mr.Svendsen,74,has just been diagnosed with pancreatic cancer,and is upset and pacing around the room.The nurse has formulated the following diagnosis: Anxiety,related to unfamiliarity of disease process,manifested by restlessness and tachycardia.What is the etiology of this diagnosis?

Accepted Answer

The etiology of the diagnosis is the reason or cause for it. In this case, the unfamiliarity of the disease process is the main cause of Mr.Svendsen's anxiety, restlessness, and tachycardia. Therefore, option A is the best choice. Options B, C, and D are the manifestations or symptoms of the anxiety, not the underlying cause.

Question 19

A nurse notices that there is a new area of skin breakdown near the site of a client's dressing.It appears to be caused from the tape used to secure the dressing.This would be an example of which phase of the nursing process?

Accepted Answer

The nurse is observing and gathering information about a new area of skin breakdown near the site of the client's dressing. This is part of the assessment phase of the nursing process, which involves collecting data and identifying any potential problems or risks. The other phases include diagnosis, which involves analyzing the data to identify the client's health problems or needs; implementation, which involves taking action based on the diagnosis; and evaluation, which involves determining whether the interventions have been effective.

Question 20

The nurse designs a nursing diagnosis of activity intolerance related to decreased airway capacity for a client with chronic asthma.She realizes that the client's vast knowledge about the disease serves as a coping skill.Why should the nurse utilize this information?

Accepted Answer

By utilizing the client's knowledge about their disease as a coping skill, the nurse can tap into the client's strengths and use them as an aid to mobilizing health and the healing process. This can lead to a more effective and efficient care plan.

Quiz 23: The Nursing Process