Chapter 11 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 11

Question 1

Type: MCSA

The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process?

1. Deliver care to a client in an organized way.

2. Implement a plan that is close to the medical model.

3. Identify client needs and deliver care to meet those needs.

4. Make sure that standardized care is available to clients.

Correct Answer: 3

Rationale 1: Delivery of organized care is not part of the nursing process, although each phase is interrelated.

Rationale 2: The nursing process is not part of the medical model, as nurses treat the clients response to the disease or problem.

Rationale 3: The purpose of the nursing process is to identify a clients health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs.

Rationale 4: The nursing process is individualized for each clients care plan. It is not about standardizing care.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1. Describe the phases of the nursing process.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 155

Question 2

Type: MCSA

While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working?

1. Assessment

2. Diagnosis

3. Implementation

4. Evaluation

Correct Answer: 1

Rationale 1: Assessment is the collection, organization, validation, and documentation of data. Assessment is carried throughout the nursing process, as in this case. Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment.

Rationale 2: Diagnosis is identifying the clients response to the problem. Implementation is what the nurse does to help the client reach a goal, and then the goal is evaluated.

Rationale 3: Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment.

Rationale 4: The goal of the intervention is evaluated, but that is not what is being described in this scenario.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual,

socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify the four major activities associated with the assessing phase.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 159

Question 3

Type: MCSA

During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says leave me alone. Which subjective data should the nurse document?

1. Restlessness

2. Leave me alone

3. Not talkative

4. Pale and diaphoretic

Correct Answer: 2

Rationale 1: Restlessness is observable so it is not subjective data.

Rationale 2: Subjective data can be described or verified only by that person and are apparent only to the person affected. Subjective data include the clients sensations, feelings, beliefs, attitudes, and perceptions of personal health status and life situations.

Rationale 3: Not being talkative is observable so it is not subjective data.

Rationale 4: Paleness with diaphoresis is observable so this is not subjective data.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 160

Question 4

Type: MCSA

Family of a client demonstrating confusion state that this is not the clients usual behavior. How should the nurse document this data?

1. Inference

2. Subjective data

3. Objective data

4. Secondary subjective data

Correct Answer: 3

Rationale 1: Inference is making a judgment, and that is not what is described in the question.

Rationale 2: The information provided by the spouse is not subjective because it is an observation by someone familiar with the clients usual behavior.

Rationale 3: Information supplied by family members, significant others, or other health professionals are considered subjective if it is not based on fact. Because this information is factual, in that the spouse is able to provide the nurse with information about the clients routine behavior and patterns, this is objective data.

Rationale 4: The information provided by the spouse is not subjective because it is an observation by someone familiar with the clients usual behavior.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 160

Question 5

Type: MCSA

The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the clients pain. Which phase of the nursing process is this nurse implementing?

1. Assessment

2. Diagnosis

3. Implementation

4. Evaluation

Correct Answer: 3

Rationale 1: Assessment is gathering data, and this is not what is described in the question.

Rationale 2: Diagnosis is identifying patterns and making inferences, and this is not what is described in the question.

Rationale 3: Implementation is that part of the nursing process in which the nurse applies knowledge to perform interventions.

Rationale 4: Evaluation is making criterion-based evaluations, and this is not what is described in the question.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe the phases of the nursing process.

MNL Learning Outcome: 1.4.3. Distinguish the nurses role in the implementation phase of the nursing process.

Page Number: 159

Question 6

Type: MCSA

A new client has been admitted to the care area. How soon should the nurse plan to complete a physical assessment on this patient?

1. 1 hour

2. 12 hours

3. 48 hours

4. 24 hours

Correct Answer: 4

Rationale 1: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 1 hour.

Rationale 2: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 12 hours.

Rationale 3: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 48 hours.

Rationale 4: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within 24 hours of admission as an inpatient.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10. Contrast various frameworks used for nursing assessment.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 159

Question 7

Type: MCSA

The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client?

1. Medical record from the childs birth

2. Grandmother

3. Parents

4. Admitting physician

Correct Answer: 3

Rationale 1: The babys birth record is able to provide necessary information, but not to the same extent as the parents.

Rationale 2: Although the grandmother can support the parents during this time and may be able to offer some helpful information, she would not be the best source.

Rationale 3: The best source of data is usually the client, unless the client is too ill, young, or confused to communicate clearly. The parents would be able to provide the nurse with the most accurate, current information regarding the baby (diet, schedule, symptoms, etc.).

Rationale 4: The admitting physician will be able to provide necessary information, but not to the same extent as the parents.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 161

Question 8

Type: MCSA

A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client?

1. In order to make sure all of your information is complete, I need to ask these questions.

2. Youre right. Let me know if theres anything you need right now.

3. Ill be done shortly, just give me a few more minutes.

4. You shouldnt be upset. Were only doing our jobs.

Correct Answer: 2

Rationale 1: Before asking more questions, the nurse should review what is already at hand.

Rationale 2: Repeated questioning can be stressful and annoying, especially for hospitalized clients, and cause concern about the lack of communication among health professionals. The nurse should review previous records that contain data about the clients occupation, religion, and marital status, as well as take time to review all the information the previous nurse collected. Validating the clients feelings is always a good idea and helps to build rapport between the nurse and client.

Rationale 3: This option does not address the clients legitimate concern, nor does it acknowledge the clients feelings.

Rationale 4: Telling the client were only doing our jobs is belittling to the client and doesnt offer a therapeutic response.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe important aspects of the interview setting.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 163

Question 9

Type: MCSA

The nurse documents: Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse. Which method of data collection does this documentation demonstrate?

1. Examining

2. Interviewing

3. Listening

4. Observing

Correct Answer: 4

Rationale 1: Examining is the major method used in the physical health assessment.

Rationale 2: Interviewing is used mainly while taking the nursing health history.

Rationale 3: Listening is only one part of observing.

Rationale 4: Observation is a conscious, deliberate skill that is developed through effort and with an organized approach. Observation occurs whenever the nurse is in contact with the client or support persons.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 164

Question 10

Type: MCSA

A nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for this particular nurse?

1. A client with audible breathing

2. Moaning of a client in pain

3. Whirring of ventilators

4. Co-orkers discussing their clients conditions

Correct Answer: 3

Rationale 1: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurses part). Listening to a clients breathing helps the nurse become attentive to changes in breathing patterns.

Rationale 2: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurses part). A clients moans of pain should never become easy to listen to.

Rationale 3: The noises of machines and other equipment noisesexcept alarmswould be easy to ignore, as these are the usual, normal sounds of the unit.

Rationale 4: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurses part). Listening to coworkers discuss other clients on the unit is helpful in case the nurse has to attend to any one of them.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10. Contrast various frameworks used for nursing assessment.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 165

Question 11

Type: SEQ

A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority).

Standard Text: Click and drag the options below to move them up or down.

Choice 1. The family is at the bedside.

Choice 2. The IV pump is running on battery.

Choice 3. The ECG monitor shows tachycardia.

Choice 4. The client reports being restless.

Choice 5. O2 tubing is not attached to wall regulator.

Correct Answer: 3, 4, 5, 2, 1

Rationale 1: Has no apparent bearing on clients symptoms

Rationale 2: Indicates an issue worth observing

Rationale 3: Indicates an objective cardiac symptom

Rationale 4: Indicates a subjective symptom

Rationale 5: Indicates a possible cause of the clients symptoms

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify the purpose of assessing.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 164

Question 12

Type: MCSA

During an initial interview, the client says I dont understand why I have to have surgery; Im really not that sick or in pain right now. How should the nurse respond to the client?

1. Its OK to be worried. Surgery is a big step.

2. What kind of questions do you have about your surgery?

3. I think these are things you should be asking your doctor.

4. Have you had surgery before?

Correct Answer: 2

Rationale 1: Simply noting the concern, without dealing with it, can leave the impression that the nurse does not care about the clients concerns or dismisses them as unimportant.

Rationale 2: The nurse should use a combination of directive and nondirective approaches during the interview to determine areas of concern for the client.

Rationale 3: Passing the questions off for the doctor would leave the impression that the nurse does not care about the clients concerns or dismisses them as unimportant.

Rationale 4: A closed question (Have you had surgery before?) does not allow the client to offer much information, besides yes/no or one-word answers.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 164

Question 13

Type: MCSA

The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use?

1. How would you describe your sleep pattern?

2. Can you describe your coughing pattern?

3. Is there anything that makes your breathing worse?

4. What medications are you on?

Correct Answer: 1

Rationale 1: Open-ended questions invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings. They specify only the broad topic to be discussed. Open-ended questions invite long answerslonger than one or two words.

Rationale 2: Closed questions can be answered with short, factual, and specific information.

Rationale 3: Closed questions can be answered with short, factual, and specific information.

Rationale 4: Closed questions can be answered with short, factual, and specific information.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 164

Question 14

Type: MCSA

The nurse is assessing a clients level of pain. Which open-ended question should the nurse use for this situation?

1. Is your pain worse at night?

2. What brought you to the clinic?

3. How has the pain impacted your life?

4. Youre feeling down about having pain, arent you?

Correct Answer: 3

Rationale 1: Closed questions can be answered with one or two words.

Rationale 2: A neutral question is open-ended and is used in nondirective interviews, which is what would be used if the nurse didnt understand the reason for the clients visit.

Rationale 3: An open-ended question would be beneficial to explore more about the clients experience and should be asked with a how or what.

Rationale 4: A leading question is usually closed and directs the clients answer (the nurse stating how the client is feeling, for example).

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 164

Question 15

Type: MCSA

A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, what should the nurse do?

1. Sit next to the client, a few feet apart.

2. Sit behind a desk.

3. Stand at the side of the clients chair.

4. Stand at the counter to take notes during the interview.

Correct Answer: 1

Rationale 1: A seating arrangement in which the client and nurse are seated in chairs, a few feet apart, at right angles to each other and with no table between, creates a less formal atmosphere, with the nurse and client feeling on equal terms. This would allow for more comfort and relaxation during the interview phase.

Rationale 2: Sitting behind a desk creates a formal arrangement that suggests a business meeting between a superior and subordinate.

Rationale 3: Standing and looking down at a client who is in a chair risks intimidating the client.

Rationale 4: Standing and taking notes infers that the nurse is not really interested in the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe important aspects of the interview setting.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 165

Question 16

Type: MCSA

A client in the emergency department has a non-lifethreatening wound. The unit is busy with other clients, families, and people in the waiting room. How should the nurse conduct an interview with this client?

1. Have the client wait until the department quiets down, as the wound is not too serious.

2. Tell the client to wait in the waiting room and fill out the paperwork.

3. Draw curtains around the client and nurse to provide as much privacy as possible.

4. Make sure the clients back is to the rest of the room so as not to be heard by passersby.

Correct Answer: 3

Rationale 1: Having the client wait may cause an unnecessary delay in treatment.

Rationale 2: Having the client wait and fill out paperwork may cause an unnecessary delay in treatment.

Rationale 3: The interview setting should be in a well-lighted, well-ventilated room that is relatively free of noise, movements, and distractions in order to encourage communication. The interview should also take place in an area where others cannot overhear or see the client if possible. In this situation, at least pulling a privacy curtain will help keep the client from view of others in the department.

Rationale 4: Making sure the clients back is to the rest of the room is not acceptable.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Compare directive and nondirective approaches to interviewing.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 165

Question 17

Type: MCSA

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

1. As soon as the client gets to the floor

2. After the client has settled in and been oriented to the room

3. When the family is available to help

4. After the client has been medicated

Correct Answer: 2

Rationale 1: Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal.

Rationale 2: After the client has been oriented to the bathroom and nurse call light, the nurse should start the interview process. In this situation, the nurse may have to pace the interview according to the clients comfort level.

Rationale 3: Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal.

Rationale 4: Medication may affect the clients ability to think clearly, so getting as much information as quickly as possible is important.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9. Describe important aspects of the interview setting.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 165

Question 18

Type: MCSA

A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client?

1. Have a member of the housekeeping staff who speaks the same language translate.

2. Use the translation services supplied by the hospital.

3. Make sure a family member who does speak English is available.

4. Conduct the interview using hand gestures.

Correct Answer: 2

Rationale 1: Nurses must be cautious when asking family members, client visitors, or agency nonprofessional staff to assist with translation. Issues of confidentiality or gender mismatch can interfere with effective communication.

Rationale 2: Live translation is preferred because the client can then ask questions for clarification. Many large facilities are establishing their own translator services for the languages commonly spoken in their geographical regions.

Rationale 3: Nurses must be cautious when asking family members, client visitors, or agency nonprofessional staff to assist with translation. Issues of confidentiality or gender mismatch can interfere with effective communication.

Rationale 4: Using hand gestures is not an appropriate way to communicate with a client when other options are available.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 166

Question 19

Type: MCSA

The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this client?

1. Hello, Im your nurse and Ill be taking care of you today.

2. Youre luckythere are no students on the unit today.

3. Good morning, is there anything you need right now?

4. Hi. If you need anything, put on your call light.

Correct Answer: 1

Rationale 1: Establishing rapport is a process of creating goodwill and trust and usually begins with a greeting and self-introduction, accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner. Making introductions, especially offering the use of name, is especially good in establishing rapport.

Rationale 2: Telling a hospitalized client he or she is lucky is probably not the best therapeutic comment.

Rationale 3: Establishing rapport is a process of creating goodwill and trust and usually begins with a greeting and self-introduction, accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner.

Rationale 4: Establishing rapport is a process of creating goodwill and trust and usually begins with a greeting and self-introduction, accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 166

Question 20

Type: MCSA

The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the interview is in the closing phase?

1. Im going to set up your physical assessment now. Do you have any questions?

2. Tell me more about how you feel.

3. Could you give examples of what types of other treatments youve had?

4. Is there anything youre worried about?

Correct Answer: 1

Rationale 1: Closing the interview is important for maintaining the rapport and trust between the client and nurse as well as to facilitate future interactions. The closing should contain an offer for questions, conclusions, plans for the next meeting, and a summary to verify accuracy.

Rationale 2: This would be part of the body of the interviewquestions designed to gather the most information about the situation.

Rationale 3: This would be part of the body of the interviewquestions designed to gather the most information about the situation.

Rationale 4: This would be part of the body of the interviewquestions designed to gather the most information about the situation.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 167

Question 21

Type: MCSA

During an assessment interview, the client states that an elective surgical procedure will not be done because it does not fit into the clients life goals. Into which of Gordons functional health patterns should the nurse identify this clients comment?

1. Cognitive/perceptual pattern

2. Coping/stress-tolerance pattern

3. Health-perception/health-management pattern

4. Value/belief pattern

Correct Answer: 4

Rationale 1: Cognitive perceptual patterns describe sensory-perceptual and cognitive patterns.

Rationale 2: Coping/stress-tolerance patterns describe the clients general coping pattern and the effectiveness of the patterns in terms of stress tolerance.

Rationale 3: Health-perception/health-management pattern describes the clients perceived pattern of health and well-being and how health is managed.

Rationale 4: The value/belief pattern describes the patterns of values, beliefs (including spiritual), and goals that guide the clients choices or decisions. The client in this situation has decided against a surgical procedure because it doesnt coincide with the clients beliefs and goals.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 10. Contrast various frameworks used for nursing assessment.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 170

Question 22

Type: MCSA

The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to this conclusion?

1. Observation of cues

2. Validation

3. Inference

4. Judgment

Correct Answer: 3

Rationale 1: Cues are subjective or objective data that can be directly observed by the nurse.

Rationale 2: Validation is the act of double-checking or verifying data to confirm that they are accurate and factual.

Rationale 3: Inferences are the nurses interpretations of conclusions made based on the cues, which in this case would be the frequent visits to the emergency department and the clients injuries. Data must be based on cues, and the nurse must be careful not to jump to conclusions.

Rationale 4: Judgment is not part of validation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7. Compare directive and nondirective approaches to interviewing.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 172

Question 23

Type: MCMA

The nurse is reviewing the nursing process with a firstyear nursing student. What should the nurse explain as being the purpose of the diagnosis phase?

Standard Text: Select all that apply.

1. Develop a list of problems.

2. Identify client strengths.

3. Develop a plan.

4. Specify goals and outcomes.

5. Identify problems that can be prevented.

Correct Answer: 1, 2, 5

Rationale 1: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems.

Rationale 2: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems.

Rationale 3: Developing a plan is part of the planning phase.

Rationale 4: Specifying goals and outcomes is part of the planning phase.

Rationale 5: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1. Describe the phases of the nursing process.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 156

Question 24

Type: MCSA

The nurse decides to seek wound care alternatives for a clients stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning?

1. Diagnosis

2. Implementation

3. Evaluation

4. Assessment

Correct Answer: 3

Rationale 1: Diagnosis is problem identification.

Rationale 2: Implementation is carrying out (or delegating) the planned nursing interventions. Wound care would be the implementation of this particular case.

Rationale 3: Evaluation is measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement. Activities of evaluation include judging whether goals/outcomes have been achieved and making decisions about problem status. The clients wound is not healing and the nurse decides to modify the nursing interventions.

Rationale 4: Assessment is collecting and organizing data.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1. Describe the phases of the nursing process.

MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client.

Page Number: 156

Question 25

Type: MCSA

While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time?

1. Initial assessment

2. Problem-focused assessment

3. Emergency assessment

4. Time-lapsed assessment

Correct Answer: 3

Rationale 1: Initial assessment is performed within a specific time after admission to a health care agency.

Rationale 2: Problem-focused assessment is an ongoing process integrated with nursing care.

Rationale 3: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems.

Rationale 4: Time-lapsed assessment occurs several months after the initial assessment to compare the clients current status to baseline data previously obtained.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 161

Question 26

Type: MCSA

Unlicensed assistive personnel measure a newly admitted clients vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data?

1. Retake the vital signs.

2. Call the physician.

3. Continue with the physical assessment as soon as possible.

4. Report the findings to the charge nurse.

Correct Answer: 1

Rationale 1: Guidelines for validating assessment data that are out of normal range include repeating the measurements, using another piece of equipment as needed to confirm abnormalities, or asking someone else to collect the same data. In this situation, the nurse needs to be sure that the vital signs are accurate.

Rationale 2: Calling the physician would be premature.

Rationale 3: The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated.

Rationale 4: Reporting the findings to the charge nurse before they have been validated would be premature.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 171

Question 27

Type: MCMA

A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database?

Standard Text: Select all that apply.

1. Reports from physical therapy the client received as an outpatient

2. Documentation of the nurses physical assessment

3. Physicians orders

4. A list of current medications

5. Information about the clients cultural preferences

6. Discharge instructions

Correct Answer: 1, 2, 4, 5

Rationale 1: The database is all the information about a client. It includes the nursing health history, physical assessment, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

Rationale 2: The database is all the information about a client. It includes the nursing health history, physical assessment, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

Rationale 3: The database is all the information about a client. It includes the nursing health history, physical assessment, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. It would not include the physicians orders for this admission, or discharge instructions.

Rationale 4: The database is all the information about a client. It includes the nursing health history, physical assessment, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Current medications would be a part of this database.

Rationale 5: The database is all the information about a client. It includes the nursing health history, physical assessment, cultural preferences, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

Rationale 6: The database is all the information about a client. It includes the nursing health history, physical assessment, the physicians history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. It would not include discharge instructions.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 160

Question 28

Type: MCMA

The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing effective communication guidelines?

Standard Text: Select all that apply.

1. Looking directly at the client to ensure good eye contact

2. Managing the conversation to avoid periods of silence

3. Providing personal experiences to help the client focus

4. Sitting in a chair next to the client who is in bed

5. Keeping arms unfolded and in a relaxed position

Correct Answer: 1, 4, 5

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