Question 1

The novice nurse working on a medical-surgical unit is preparing a plan of care for a client admitted for irritable bowel syndrome. The goal statement is, "The client will resume normal bowel elimination patterns." When reviewing the plan of care with the novice nurse, which statement by the preceptor is the most appropriate?

Accepted Answer

Goal statements should include a time frame, such as "the client will resume normal bowel elimination patterns within 48 hours." This adds specificity and allows for progress to be tracked. The other statements are not necessarily incorrect, but B is the most relevant to the goal statement.

Question 2

The nurse educator is discussing Healthy People 2020 with a group of nursing students. One of the students questions the instructor how this work will impact hospitalization. Which response by the educator is the most appropriate?

Accepted Answer

Healthy People 2020 seeks to improve the overall health of the population and prevent illnesses, disabilities, and premature death. This will ultimately impact hospitalization rates, as healthier individuals are less likely to require hospitalization.

Question 3

The nurse is conducting a workshop on wellness and health promotion using the initiatives of Healthy People 2020. After the session, which statement by a participant indicates an understanding of the initiatives?

Accepted Answer

The statement "Healthy People 2020 seeks to promote health, prevent illness, disability, and premature death" accurately reflects the goals of the initiative. The other options are incorrect: A is incorrect because Healthy People 2020 is not designed to assist health care providers in lobbying for more funding; B is incorrect because Healthy People 2020 covers a wide range of health concerns beyond premature birth; and D is incorrect because the initiatives do not outline standards of care for managing diseases, but rather focus on promoting overall health and wellness.

Question 4

A novice nurse is conducting a focused interview on an older adult client who is being admitted for a urinary tract infection (UTI). Which action by the novice nurse is appropriate?

Accepted Answer

Assessing the characteristics of the client's pain is appropriate during a focused interview as it helps in understanding the client's current condition and symptoms related to the UTI.

Question 5

The nurse is preparing a teaching plan for a client diagnosed with hypertension. Which objective is appropriate when addressing the psychomotor domain for the client?

Accepted Answer

The psychomotor domain involves physical movement and coordination, so demonstrating how to monitor one's own blood pressure is an appropriate objective in this domain. A, B, and D are objectives in the cognitive domain, which involves knowledge, understanding, and mental processes.

Question 6

The community health nurse is preparing to conduct a program for a group of nursing students concerning health and wellness. Which statement by a participant indicates the most comprehensive and accurate understanding of health?

Accepted Answer

Option D is the most comprehensive and accurate understanding of health as it defines health as complete physical, mental, and social well-being. This definition addresses the individual's overall well-being, including non-physical aspects such as mental and social well-being. Option A is limited and only focuses on the absence of disease, while option B may be too broad and does not encompass all aspects of health. Option C may be too vague as it only mentions that a person is viewed as a holistic being without elaborating on what that means for health.

Question 7

The nurse is caring for a newly admitted client with Methicillin-resistant Staphylococcus Aureus (MRSA). Which are appropriate goals for the initial health assessment?

Accepted Answer

The answer of The nurse is caring for a newly...

Question 8

The nurse is completing an admission assessment. The assessment form allows for the separation of subjective and objective data. Which data is considered subjective?

Accepted Answer

Subjective data is information that the client or others provide that cannot be seen or measured, such as feelings, experiences, and symptoms. In this case, the client's mother informing the nurse about her daughter's pain and the client's statement about the intensity of her pain are subjective data. The other options are objective data because they can be measured, observed, or tested, such as physical findings or observable behaviors.

Question 9

The nurse is reviewing a client's medical record while planning care. Which data from the medical record is an example of objective data?

Accepted Answer

Objective data is factual information that is observed or measured by the nurse. In this scenario, the description of the client, "Six-year-old Hispanic female sitting on examination table holding a towel to her forehead," is an example of objective data that can be observed by the nurse. Answer A is subjective data because it is the client's own perception of the situation. Answer B includes some objective data (the client's age) but also includes subjective information (the reason for the visit). Answer D is also subjective data because it is the client's report of what happened.

Question 10

The nurse is developing the plan of care for a client who is recovering from abdominal surgery. Which intervention is most appropriate to address this client's pain?

Accepted Answer

Guided imagery is a non-pharmacological intervention that can help manage pain levels, making it an appropriate choice for addressing pain in a care plan.

Question 11

The nurse educator is presenting information about the nursing process to a group of students. Which statement by a student reflects the appropriate sequence when implementing the nursing process?

Accepted Answer

The correct sequence of the nursing process is assessment, diagnosis, planning, implementation, and evaluation, as outlined in Option B. This sequence ensures that the nurse gathers all the necessary information before making a diagnosis, formulates a plan of care specific to the patient's needs, and evaluates the effectiveness of the interventions.

Question 12

The nurse is caring for a client who is recovering from abdominal surgery. Which goal statement is most appropriate for the nurse to include in this client's plan of care?

Accepted Answer

Goal statements should be specific, measurable, and related to the client's condition. Option A is a clear, measurable goal that is related to the client's recovery from surgery. Option B is not a specific goal and does not address the client's pain level or overall condition. Option C is not a client-centered goal and relies on the nurse's interpretation of the client's behavior. Option D is a nursing intervention rather than a client goal.

Question 13

The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. Which action by the nurse is the most appropriate?

Accepted Answer

The nurse should review the data and modify the plan accordingly to increase the chances of achieving the goals. Reporting to the healthcare provider or reformulating the nursing diagnosis may be necessary, but these actions should come after a review of the data and modification of the plan. Requesting a consult for a pulmonologist may be necessary if the client's condition is worsening or if the nurse feels that the client is not responding to treatment. However, this action should also come after a review of the data and modification of the plan.

Question 14

While conducting a health history, a client states, "I am healthy, I don't know why I have to be here to get a check-up." However, the client reports, type 2 diabetes mellitus and an unhealed ulcer on the left foot. Based on this information, which statement by the nurse is the most appropriate?

Accepted Answer

This response allows the client to explain their perspective on their health status and their definition of "healthy." It also opens the opportunity for the nurse to provide education on the importance of regular check-ups and managing chronic conditions. The other responses may be perceived as confrontational or may close communication with the client.

Question 15

Which statement best describes the active role of the professional nurse as an educator?

Accepted Answer

The active role of the professional nurse as an educator involves considering various factors such as learning needs, goals, objectives, content, teaching methods, and evaluation when providing client education. This ensures that the education is effective and meets the needs of the client. Option B is a limited view as it only addresses the development of teaching plans for informal teaching. Option C suggests the nurse should refer to other healthcare providers, which is not always feasible or necessary. Option D suggests that teaching can be delegated to others, but it is ultimately the nurse's responsibility to ensure that the patient receives education and has understood the information provided.

Question 16

While conducting a physical assessment for a client with asthma, the nurse notes that the client is wheezing and documents this finding in the medical record. Which phase of critical thinking is represented by this nurse's actions?

Accepted Answer

The nurse's action of documenting the client's wheezing is part of the collection of information phase of critical thinking.

Question 17

The nurse is admitting a client to a mental health unit for an exacerbation of bipolar disorder. When conducting the health history for this client, which is important to keep in mind regarding the client's confidentiality?

Accepted Answer

Confidentiality in healthcare means that information sharing is limited to those directly involved in the client's care. This includes the healthcare team members who are directly involved in providing care to the client. HIPAA regulations protect the client's confidentiality and provide guidelines to follow. The medical records are not open to any hospital employee, including administration.

Question 18

The nurse conducts a health history while admitting a client to the acute care facility. When collecting primary subjective data, which is an appropriate source for the nurse to use?

Accepted Answer

Primary subjective data is information about health-related experiences that can only be provided by the person experiencing them. Self-reports from the client are an appropriate source for collecting primary subjective data. The other options may provide important information, but they are not considered primary subjective data.

Question 19

The nurse is assessing a client who presents in the emergency department (ED) with abdominal pain, nausea, and vomiting. Vital signs are within normal limits. The client's health history indicates pelvic inflammatory disease, mitral valve prolapse, and childbirth. When analyzing the available data, what items should be clustered together?

Accepted Answer

The client's current symptoms of abdominal pain, nausea, and vomiting are likely related to their history of pelvic inflammatory disease. Clustering these data points together can help the nurse form a hypothesis about the client's presenting problem and guide further assessment and treatment. The other options, while important pieces of information, do not have a direct or immediate impact on the client's current condition.

Question 20

The nurse is reviewing a client's medical records and notes various forms of information. Which is an example of subjective data from this client's medical record?

Accepted Answer

Subjective data is information that can only be obtained from the client's point of view, such as their symptoms or feelings. In this case, the client stating that their abdomen hurts on the left side after eating is subjective data. The other options are objective data, which can be observed or measured, such as physical exam findings, diagnostic test results, or laboratory values.

Quiz 1: Health Assessment