Question 1

Which outcome statement is a properly written goal?

Accepted Answer

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?

Accepted Answer

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:

Accepted Answer

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?

Accepted Answer

When prioritizing nursing care, the most critical problems receive the highest priority. In this scenario, the float nurse from another department serves as another health care team member unfamiliar with the medical-surgical patient population. The medical-surgical RN serves as an all-around organizer of care and interventions that other health care team members provide. The patient with COPD and viral pneumonia is the most stable of the group. The patient with A-Fib, the post open heart surgery patient with dangerously low blood pressure, and the neutropenic patient awaiting chemotherapy all require close attention and advanced interventions by the RN familiar with these types of patients.

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:

Accepted Answer

The nurse should contact the family to obtain the needed information. Refusing to complete the admission without more information is not professional. Calling the doctor in the emergency room for a history is not likely to be helpful, and asking another nurse to try to obtain the information from the patient is not likely to change the outcome because of the patient's cognitive status.

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:

Accepted Answer

The information in the patient's statement relates to risk factors that may cause cardiovascular problems in the future. Identification of risk factors falls into the health perception-health management pattern. This pattern describes a patient's perceived pattern of health and how health is managed.

Question 7

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

Accepted Answer

Remember your ABCs. Airway is always a priority. Pain, activity intolerance, and deficient knowledge are not priorities.

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?

Accepted Answer

The nurse would evaluate the effectiveness of the incentive spirometer treatment by listening for adventitious lung sounds. Asking whether the patient is breathing better; adding turn, cough, and deep breathing exercises; and watching the patient using the incentive spirometer do not examine the effectiveness of the plan of care.

Question 9

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

Accepted Answer

A reasonable outcome is that the patient's mobility will increase as pain decreases. "Care for the catheter independently" is incorrect because the patient would not be expected to have a catheter. "Walking without assistance" and "bathe daily in a tub" are not reasonable for the patient 12 hours status post hip replacement.

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?

Accepted Answer

Replacing fluids is the priority. Anorexia is common in the elderly and can be related to many conditions, including dementia. Fluid volume excess is not present. Risk for impaired skin integrity is not the priority.

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?

Accepted Answer

Safety is the first priority for this patient who is cognitively and visually impaired, wanders, and is unsteady. Laboratory results should be monitored, but safety is the priority. Skin condition and nutrition are of concern but are not immediate priorities.

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?

Accepted Answer

Pain is the first priority for the patient admitted for rehabilitation following surgical intervention. Self-care ability and self-esteem are not the first to be assessed. The ability to communicate pain can be facilitated using graphic representations if the patient does not speak English.

Question 13

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

Accepted Answer

The patient's being able to stand and walk is the correct answer. The nurse focuses on functional abilities and deficits in order to focus the plan of care and help identify the outcome priorities. These areas are not generally assessed by the physician. The patient's feeling fearful of his disposition at discharge is incorrect because the nursing patient assessment does not focus on feelings and behavior. In addition to subjective data illustrated here by the patient's stating the location of his pain, the nurse also uses objective data for the nursing patient assessment. The statement describing the patient's medical history is not the focus of a nursing patient assessment.

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?

Accepted Answer

Licensed practical nurses can implement actions specific to the patient care needs. Monitoring the stroke patient and maintaining the continuous feeding is an appropriate delegation. LPNs can also collect data, perform basic teaching, record data as well as interventions, and report to the RNs the progress the patient is making. The patient one-day post-op from the right lower lobectomy, the patient with the hip replacement, and the patient with the appendectomy are inappropriate to delegate to a LPN because each requires a focused assessment, advanced interventions, evaluation, and updating of the patients' plans of care and outcome priorities.

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):

Accepted Answer

An outcome measures the effectiveness of the plan of care. An intervention, a plan, and a diagnosis or analysis are incorrect.

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?

Accepted Answer

"The patient's pain will decrease to 2 or lower by the end of shift on (date)" states what is to be measured, how much it will decrease, and by when. "The patient's pain will be under control by Sunday," "The patient will have no pain by the end of this shift," and "The patient's pain will decrease by the end of shift on (date)" do not include these elements.

Question 17

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

Accepted Answer

Remember your ABCs. The highest priority for this patient is to conserve energy. Constipation related to immobility, risk for infection related to IV lines, and self-care deficit are not priorities.

Question 18

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

Accepted Answer

Measurability provides the means to evaluate outcomes consistently. The outcome criterion of listing the specific signs of infection is consistently measurable by anyone choosing to attain that outcome criterion. Being pain-free and then walking to the bathroom is not measurable because one outcome criterion cannot depend on completion of another criterion. Each outcome criterion is considered an individual goal. The statements addressing abdominal pain and nausea, vomiting, diarrhea are collected data and taking account of the pain medications administered to the patient have nothing in common with measurability.

Question 19

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

Accepted Answer

Planning goals and desired outcomes occurs in the planning phase. The plan of care includes the process of identifying the interventions needed for the patient to regain a level of independence at or higher than the patient had before admission into the hospital.

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?

Accepted Answer

The patient's stating two lifestyle modifications for weight management is reasonable and measurable. The patient's being compliant with the treatment regimen is vague. The patient's understanding the disease process does not state how the effectiveness of teaching will be measured (e.g., by return demonstration or verbalization). The patient's blood pressure not increasing is not reasonable.

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