Question 1

Rank the patient needs according to Maslow's hierarchy, beginning with the lowest level need to the highest level need. &#10;A) A patient would like to write a book.&#10;B) A patient becomes frightened when no one answers the call light during the night.&#10;C) A pediatric patient is worrying that school friends will forget him.&#10;D) A patient needs to be repositioned in bed.&#10;E) A chronically ill patient states that he feels worthless because he is unable to support his family.

Accepted Answer

Maslow's hierarchy of needs begins with the physiological needs (e.g., food, water, shelter), followed by safety needs (e.g., physical and emotional safety), love and belonging needs (e.g., social interaction, relationships), esteem needs (e.g., feeling valued and respected), and self-actualization needs (e.g., fulfilling one's potential, creativity). Repositioning the patient in bed addresses the lowest level physiological need of comfort and prevention of complications such as pressure ulcers. Answering the call light addresses the safety need of timely assistance. The worry about school friends is related to love and belonging needs, and feeling worthless because of inability to support family is related to esteem needs. Writing a book is related to self-actualization needs, at the highest level of the hierarchy.

Question 2

What is the primary purpose of the nursing assessment?&#10;A) Identifying underlying pathologic conditions&#10;B) Assisting the physician in identifying medical conditions&#10;C) Determining the patient's mental status&#10;D) Exploring patient responses to health problems

Accepted Answer

The primary purpose of the nursing assessment is to explore patient responses to health problems, including physical, emotional, and social responses. While identifying underlying pathologic conditions and assisting the physician in identifying medical conditions may be part of the assessment process, they are not the primary purpose. Determining the patient's mental status may also be important, but it is not the primary purpose of the assessment.

Question 3

Which are ways to distinguish a nursing diagnosis from a medical diagnosis? (Select all that apply.)&#10;A) Statement of the patient's alterations in structure and functions&#10;B) Description of the patient's ability to function in relation to impairment&#10;C) Tend to remain the same throughout the course of illness or recovery from injury&#10;D) Varies depending on patient's state of recovery&#10;E) Based on research done by nurses&#10;F) Conditions can be accurately identified by nursing assessment methods

Accepted Answer

Nursing diagnoses focus on the patient's response to health conditions and their ability to function, vary with recovery, are based on nursing research, and can be identified through nursing assessments.

Question 4

Which is the priority nursing diagnosis for an older adult with diabetes hospitalized for pneumonia?&#10;A) Deficient Knowledge related to lack of information about diabetic medication&#10;B) Risk for Falls related to weakness&#10;C) Impaired Gas Exchange related to decreased pulmonary ventilation&#10;D) Imbalanced Nutrition: More than Body Requirements related to obesity

Accepted Answer

The priority nursing diagnosis for an older adult with diabetes hospitalized for pneumonia is Impaired Gas Exchange related to decreased pulmonary ventilation as pneumonia affects the lungs' ability to exchange oxygen and carbon dioxide, which can be life-threatening, especially in individuals with pre-existing conditions like diabetes. Deficient Knowledge and Imbalanced Nutrition: More than Body Requirements may be relevant, but they are of lower priority, whereas Risk for Falls is not directly related to the diagnosis and can be addressed with appropriate interventions.

Question 5

Which type of nursing diagnosis will be written when the patient exhibits factors that makes them susceptible to the development of a problem?&#10;A) Actual diagnosis&#10;B) Risk diagnosis&#10;C) Possible diagnosis&#10;D) Wellness diagnosis

Accepted Answer

A risk diagnosis is written when the patient does not currently have the problem, but exhibits factors that make them susceptible to its development in the future. This allows for nursing interventions to prevent the problem from occurring or worsening.

Question 6

Prior to the administration of a nephrotoxic drug, the nurse determines that the kidney lab data are within normal range. Which step of the nursing process is being utilized?&#10;A) Assessment&#10;B) Nursing diagnosis&#10;C) Planning&#10;D) Evaluation

Accepted Answer

By determining the kidney lab data are within normal range, the nurse is performing an assessment and gathering information about the patient's current status before administering a potentially harmful medication.

Question 7

When a nursing diagnosis statement is written, who or what directs the nurse to identify appropriate nursing interventions?&#10;A) Other nurses on staff who have experience with the diagnoses&#10;B) The patient and family who have an interest in the outcome&#10;C) The etiologies of the problems identified in the nursing diagnoses&#10;D) The medical staff who have more expertise than the nurses

Accepted Answer

The etiologies, or underlying causes, of the problems identified in the nursing diagnoses can guide the nurse in identifying appropriate nursing interventions. It is important for the nurse to identify interventions that address the root cause of the problem in order to promote effective outcomes for the patient. While input from other nurses, the patient and family, and the medical staff can also be valuable, it is ultimately the nurse's responsibility to identify appropriate interventions based on the nursing diagnosis.

Question 8

Which is true regarding critical pathways? (Select all that apply.)&#10;A) Efficient for specific diseases or case types&#10;B) The same as medical plans&#10;C) Standardized and enhance quality care&#10;D) Evaluated less frequently than care plans&#10;E) Enhance communication for a variety of health care providers

Accepted Answer

Critical pathways are standardized, disease-specific care plans that enhance communication and collaboration among healthcare providers. They are evaluated frequently and are designed to improve the quality and efficiency of care for a specific disease or case type. Unlike medical plans, they are more specific and detailed in terms of the patient's care plan. Therefore, options B and D are incorrect.

Question 9

Which statement regarding nursing diagnoses is accurate?&#10;A) Nursing diagnoses remain the same for as long as the disease is present.&#10;B) Nursing diagnoses are written to identify disease states.&#10;C) Nursing diagnoses describe patient problems that nurses treat.&#10;D) Nursing diagnoses identify causes related to illness.

Accepted Answer

Nursing diagnoses describe patient problems that nurses treat. Nursing diagnoses are clinical judgments about the patient's response to actual or potential health conditions or needs. They describe patient problems that nurses can treat, and they guide the selection of nursing interventions to achieve outcomes for which the nurse is accountable. They are not related to specific disease states or causes of illness, but rather address the patient's response to those conditions or needs. They may change as patient responses and conditions change.

Question 10

Which outcome statement identified by the nurse is written correctly?&#10;A) After surgery, patient will express acceptance of loss of breast.&#10;B) Patient will die with dignity.&#10;C) At the end of the shift the nurse will determine whether the patient is more comfortable.&#10;D) Within the next 8 hours, urine output will be greater than 30 mL/hr.

Accepted Answer

The outcome statement in option D is specific, measurable, achievable, relevant, and time-bound. It includes a timeframe (within the next 8 hours) and a measurable outcome (urine output greater than 30 mL/hr). Options A and B are vague and subjective, while option C is not really an outcome statement as it is focused on a nursing task rather than a patient outcome.

Question 11

A patient is experiencing adverse effects of a medication. Which information obtained by the nurse is subjective?&#10;A) Cough&#10;B) Edema&#10;C) Nausea&#10;D) Tachycardia

Accepted Answer

The answer of A patient is experiencing adverse effects of...

Question 12

The nurse has determined that the pain medication given to a patient an hour ago has been effective. The nurse is using which step of the nursing process?&#10;A) Evaluation&#10;B) Intervention&#10;C) Nursing diagnosis&#10;D) Planning

Accepted Answer

The answer of The nurse has determined that the pain...

Question 13

Which statement best describes the planning phase of the nursing process?&#10;A) Administer insulin subcutaneously in the abdominal area.&#10;B) High risk for falls related to hypotension&#10;C) The patient will state the expected adverse effects of medication by end of teaching session.&#10;D) Itching has resolved; medication given is effective.

Accepted Answer

The answer of Which statement best describes the planning phase...

Question 14

What is the basis of the NANDA-I taxonomy?&#10;A) Functional health patterns&#10;B) Human response patterns&#10;C) Basic human needs&#10;D) Pathophysiologic needs

Accepted Answer

The answer of What is the basis of the NANDA-I...

Question 15

What is a critical care pathway?&#10;A) A nursing care plan for a patient in a critical care unit&#10;B) A standardized care plan derived from best-practice patterns&#10;C) A care plan that has been critiqued by a quality improvement officer&#10;D) A care plan based on measurable goals and outcomes

Accepted Answer

The answer of What is a critical care pathway?&#10;A) A...

Question 16

An obese patient did not meet the goal of &#34;by the end of the second week, is able to follow a 1500-calorie diet.&#34; What will the nurse and the patient reassess?&#10;A) Patient's weight&#10;B) Patient's understanding of the 1500-calorie diet&#10;C) Nurse's feelings about obese patients&#10;D) Health care agency's ability to provide the prescribed diet

Accepted Answer

The answer of An obese patient did not meet the...

Question 17

What is the nurse's primary source of information when obtaining a patient history?&#10;A) The physician&#10;B) The patient record&#10;C) The family&#10;D) The patient

Accepted Answer

The answer of What is the nurse's primary source of...

Question 18

What do the classification systems NIC and NOC provide?&#10;A) Individualized data banks of treatments related to disease processes&#10;B) Standardized language for reporting and analyzing nursing care delivery&#10;C) A measure for cost containment within medical institutions&#10;D) Specialized interventions for rare diseases

Accepted Answer

The answer of What do the classification systems NIC and...

Question 19

Which is an example of an interdependent nursing action?&#10;A) Assess lung sounds every 4 hours.&#10;B) Educate the patient about the prescribed medication.&#10;C) Administer Demerol 50 mg IM every 4 hours PRN.&#10;D) Encourage the patient to express feelings.

Accepted Answer

The answer of Which is an example of an interdependent...

Question 20

Which task is included in the assessment step of the nursing process?&#10;A) Establishing patient goals/outcomes&#10;B) Implementation of the nursing care plan&#10;C) Measuring goal/outcome achievement&#10;D) Collecting and communicating data

Accepted Answer

The answer of Which task is included in the assessment...

Deck 4: The Nursing Process and Pharmacology