Question 1

During an intake interview,the nurse observes the patient grimacing and holding his hand over his stomach.The patient previously denied having any pain.What action should the nurse take next?

Accepted Answer

The nurse should try to resolve any incongruence between body language and verbal responses.

Question 2

The nurse is completing the medication reconciliation form for a patient.Which information is most important for the nurse to include?

Accepted Answer

As part of the medication reconciliation form,all home medications (including herbal preparations like Gingko biloba)are listed and reviewed by the provider,pharmacist,and nurses.The information gathered during the completion of this form may impact care that the patient will receive.Abnormal lab work and history of chronic or acute illnesses are important components of the patient's history but should not be part of the medication reconciliation form.

Question 3

Which technique should the nurse employ to best assess skin turgor?

Accepted Answer

Skin turgor can be assessed by tenting the skin on the chest and recording the speed at which the "tent" subsides.

Question 4

During a morning assessment,the nurse observes that the patient displays significant edema of both feet and ankles.Which statement best documents these findings?

Accepted Answer

Edema should be recorded as to location,depth of pitting,and time for resolution.

Question 5

The nurse is caring for a newly admitted patient who is describing his recent symptoms to the nurse.This scenario is an example of which type of source?

Accepted Answer

The patient is the primary source of information.Objective refers to a type of data obtained by the nurse that is measured or can be verified through assessment techniques,secondary information is obtained from relatives or significant others,and information is not necessarily complete when the patient is the source.

Question 6

The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for Impaired Skin Integrity Related to Immobility.Which goal/outcome statement best correlates with this diagnosis?

Accepted Answer

The goal/outcome statement is directed at the etiology and should be patient oriented.The statement should be realistic and measurable and reflect what the patient will do.

Question 7

Which foundational behavior is necessary for effective critical thinking?

Accepted Answer

An open attitude not clouded by unshakable beliefs and values or preset goals allows the application of critical thinking.Acceptance that there may not be a perfect solution leaves the field open to new ideas.

Question 8

The nurse is explaining the components of a complete problem statement/nursing diagnosis.In addition to the NANDA stem and etiology,which other component should the diagnosis include?

Accepted Answer

A complete problem statement/nursing diagnosis must have a NANDA stem,etiology,and signs and symptoms (etiology)of the problem.

Question 9

The nurse is performing an intake interview on a new resident to the long-term care facility.The nurse detects the odor of acetone from the patient's breath.Which term accurately describes this assessment?

Accepted Answer

Olfaction is an assessment method of smells.Inspection and observation use the sense of vision.Auscultation refers to use of the sense of hearing.

Question 10

The nurse is caring for a patient with a goal/outcome statement of Patient will sleep for 5 hours uninterrupted each night.Which nursing intervention should the nurse include?

Accepted Answer

Discouraging daytime napping increases the probability of sleep.Giving medication is a collaborative intervention as it requires an order.Large meal and large fluid intakes may interrupt sleep.

Question 11

The nurse who has recently moved from Louisiana to Texas is uncertain about the LPN/LVN's role in applying the nursing process.Which source is most appropriate source for the nurse to consult?

Accepted Answer

Each state has different guidelines for areas of care planning,intravenous therapy,teaching,and delegation.The Texas State Board of Nursing is the most reliable source.

Question 12

The nurse adds a nursing order to the care plan related to a patient with a problem statement/nursing diagnosis of altered nutrition/Nutrition: Less Than Body Requirements Related to Nausea and Vomiting.Which nursing order should the nurse include in the plan of care?

Accepted Answer

Offering crackers and iced drinks are within the scope of nursing; the other options would require a medical order to complete.

Question 13

Which fundamental belief underscores the basis of the nursing process?

Accepted Answer

The nursing process is based on the belief that all people have worth and dignity.Patient-centered care that is applied to all aspects of the patient's health,and is not just disease oriented,is appreciated by the family and patient.Holistic care approach can support the patient to meet basic needs.

Question 14

The nursing team is prioritizing the problem statement/nursing diagnoses of an overweight hospital patient.Which problem statement/nursing diagnosis would be most important for this patient?

Accepted Answer

Activity intolerance is the highest priority as it has to do with activities that are essential to life.The second is Knowledge deficit related to weight reduction diet,followed by Altered self-image related to excessive weight,and the last is Risk for dehydration related to vomiting.

Question 15

After evaluating the nursing care plan,the nurse finds lack of progress toward the goal.What action should the nurse take next?

Accepted Answer

When lack of progress to reach the goal is seen on evaluation,the interventions are reviewed and/or revised.

Question 16

Which example shows that the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA)?

Accepted Answer

HIPAA forbids any information used for educational purposes to have any identifying information; therefore,shredding documents would be appropriate.Full names on documents,printing copies of chart forms,and asking the patient for permission to copy forms would be violations of HIPAA regulations.

Question 17

The diabetic patient who had blood drawn for an HbA₁c level says,"I don't know why they want to look at my hemoglobin." Which response is most appropriate for the nurse to make?

Accepted Answer

HbA₁c evaluates the average blood glucose level for the last 2 to 3 months.By explaining the purpose of the common laboratory test (HgbA₁c)and its relationship to diabetes,the nurse answers the patient's question and clearly communicates relevant data.

Question 18

Which statement explains the reason for inclusion of potential problems in the nursing care plan?

Accepted Answer

Addressing potential problems prevents complications by early action rather than waiting for a problem to materialize.

Question 19

While conducting an admission interview,the nurse questions the patient about pain.The patient responds,"No.I'm pretty wobbly." Which action should the nurse take next?

Accepted Answer

The nurse should ask for clarification if unsure of what is meant by one of the patient's responses.

Question 20

The nurse is assessing a new patient who complains of his chest feeling tight.The patient displays a temperature of 100° F and an oxygen saturation of 89%,and expectorates frothy mucus.Which finding is an example of subjective data?

Accepted Answer

Subjective data is information given by the patient that cannot be measured otherwise.The other data are considered objective data.Objective data are pieces of information that can be measured by the examiner.The nurse should avoid making judgments or conclusions when obtaining data.

Quiz 2: Critical Thinking and the Nursing Process

During an intake interview,the nurse observes the patient grimacing and holding his hand over his stomach.The patient previously denied having any pain.What action should the nurse take next?

The nurse is completing the medication reconciliation form for a patient.Which information is most important for the nurse to include?

Which technique should the nurse employ to best assess skin turgor?

During a morning assessment,the nurse observes that the patient displays significant edema of both feet and ankles.Which statement best documents these findings?

The nurse is caring for a newly admitted patient who is describing his recent symptoms to the nurse.This scenario is an example of which type of source?

The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for Impaired Skin Integrity Related to Immobility.Which goal/outcome statement best correlates with this diagnosis?

Which foundational behavior is necessary for effective critical thinking?

The nurse is explaining the components of a complete problem statement/nursing diagnosis.In addition to the NANDA stem and etiology,which other component should the diagnosis include?

The nurse is performing an intake interview on a new resident to the long-term care facility.The nurse detects the odor of acetone from the patient's breath.Which term accurately describes this assessment?

The nurse is caring for a patient with a goal/outcome statement of Patient will sleep for 5 hours uninterrupted each night.Which nursing intervention should the nurse include?

The nurse who has recently moved from Louisiana to Texas is uncertain about the LPN/LVN's role in applying the nursing process.Which source is most appropriate source for the nurse to consult?

The nurse adds a nursing order to the care plan related to a patient with a problem statement/nursing diagnosis of altered nutrition/Nutrition: Less Than Body Requirements Related to Nausea and Vomiting.Which nursing order should the nurse include in the plan of care?

Which fundamental belief underscores the basis of the nursing process?

The nursing team is prioritizing the problem statement/nursing diagnoses of an overweight hospital patient.Which problem statement/nursing diagnosis would be most important for this patient?

After evaluating the nursing care plan,the nurse finds lack of progress toward the goal.What action should the nurse take next?

Which example shows that the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA) ?

The diabetic patient who had blood drawn for an HbA₁c level says,"I don't know why they want to look at my hemoglobin." Which response is most appropriate for the nurse to make?

Which statement explains the reason for inclusion of potential problems in the nursing care plan?

While conducting an admission interview,the nurse questions the patient about pain.The patient responds,"No.I'm pretty wobbly." Which action should the nurse take next?

The nurse is assessing a new patient who complains of his chest feeling tight.The patient displays a temperature of 100° F and an oxygen saturation of 89%,and expectorates frothy mucus.Which finding is an example of subjective data?

Quiz 2: Critical Thinking and the Nursing Process

During an intake interview,the nurse observes the patient grimacing and holding his hand over his stomach.The patient previously denied having any pain.What action should the nurse take next?

The nurse is completing the medication reconciliation form for a patient.Which information is most important for the nurse to include?

Which technique should the nurse employ to best assess skin turgor?

During a morning assessment,the nurse observes that the patient displays significant edema of both feet and ankles.Which statement best documents these findings?

The nurse is caring for a newly admitted patient who is describing his recent symptoms to the nurse.This scenario is an example of which type of source?

The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for Impaired Skin Integrity Related to Immobility.Which goal/outcome statement best correlates with this diagnosis?

Which foundational behavior is necessary for effective critical thinking?

The nurse is explaining the components of a complete problem statement/nursing diagnosis.In addition to the NANDA stem and etiology,which other component should the diagnosis include?

The nurse is performing an intake interview on a new resident to the long-term care facility.The nurse detects the odor of acetone from the patient's breath.Which term accurately describes this assessment?

The nurse is caring for a patient with a goal/outcome statement of Patient will sleep for 5 hours uninterrupted each night.Which nursing intervention should the nurse include?

The nurse who has recently moved from Louisiana to Texas is uncertain about the LPN/LVN's role in applying the nursing process.Which source is most appropriate source for the nurse to consult?

The nurse adds a nursing order to the care plan related to a patient with a problem statement/nursing diagnosis of altered nutrition/Nutrition: Less Than Body Requirements Related to Nausea and Vomiting.Which nursing order should the nurse include in the plan of care?

Which fundamental belief underscores the basis of the nursing process?

The nursing team is prioritizing the problem statement/nursing diagnoses of an overweight hospital patient.Which problem statement/nursing diagnosis would be most important for this patient?

After evaluating the nursing care plan,the nurse finds lack of progress toward the goal.What action should the nurse take next?

Which example shows that the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA) ?

The diabetic patient who had blood drawn for an HbA1c level says,"I don't know why they want to look at my hemoglobin." Which response is most appropriate for the nurse to make?

Which statement explains the reason for inclusion of potential problems in the nursing care plan?

While conducting an admission interview,the nurse questions the patient about pain.The patient responds,"No.I'm pretty wobbly." Which action should the nurse take next?

The nurse is assessing a new patient who complains of his chest feeling tight.The patient displays a temperature of 100° F and an oxygen saturation of 89%,and expectorates frothy mucus.Which finding is an example of subjective data?

The diabetic patient who had blood drawn for an HbA₁c level says,"I don't know why they want to look at my hemoglobin." Which response is most appropriate for the nurse to make?