Chapter 11 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 11

Question 1

Type: MCSA

When learning how to implement the nursing process into a plan of care for a client, the student nurse realizes that part of the purpose of the nursing process is to:

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 or organized care is not part of the nursing process, though 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:
Page Reference: 178

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe the phases of the nursing process.

Question 2

Type: MCSA

The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process?

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 item..

Global Rationale: Page Reference: 180

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Identify the four major activities associated with the assessing phase.

Question 3

Type: MCSA

The nurse is taking information for the clients database. The client is not very talkative; is pale, diaphoretic, and restless in the bed; and tells the nurse to just leave me alone. Which of the following is an example of subjective data regarding this client?

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 an example of 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 an example of subjective data.

Rationale 4: Paleness with diaphoresis iare observable so it is not an example of subjective data.

Global Rationale: Page Reference: 183

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Differentiate objective and subjective data and primary and secondary data.

Question 4

Type: MCSA

The nurse is collecting information from a clients family. The client is confused and not able to contribute to the conversation. The spouse states, This is not his normal behavior. The nurse documents this as which of the following?

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 since it is an observation by someone familiar woth the clients usual behavior.

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

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

Global Rationale: Page Reference: 183

Cognitive Level: Understanding

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome:

Question 5

Type: MCSA

A nurse is providing a back rub to a client just 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: Page Reference: 181-182

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Identify major characteristics of the nursing process.

Question 6

Type: MCSA

A nurse has just been informed that a new admission is coming to the unit. According to the 2005 JCAHO requirements, how long does the nurse have to complete a physical assessment and have a documented history and physical on the chart?

1. 1 hour

2. 12 hours

3. 48 hours

4. 24 hours

Correct Answer: 4

Rationale 1: While the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each client have an initial assessment consisting of a history and physical performed and documented within specific time period but not 1 hour.

Rationale 2: While the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each client have an initial assessment consisting of a history and physical performed and documented within specific time period but not 12 hours.

Rationale 3: While the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each client have an initial assessment consisting of a history and physical performed and documented within specific time period but not 48 hour.

Rationale 4: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 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: Page Reference: 180

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

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

Question 7

Type: MCSA

An infant has been admitted to the pediatric unit. The parents are quite worried and upset, and the grandmother is also present. In this situation, what would be the best source of data?

1. Medical record from the childs birth

2. Grandmother, since the parents are upset

3. Parents

4. Admitting physician

Correct Answer: 3

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

Rationale 2: While 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. Even though the parents are upset, they 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 extent as the parents.

Global Rationale: Page Reference: 180-181

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Identify three methods of data collection, and give examples of how each is useful.

Question 8

Type: MCSA

A client was admitted just prior to the shift change. The admitting nurse reported most of the information to oncoming staff, but did not have all of the clients past records. The second nurse is completing the assessment and database and continues to question the client about much of the same information as the previous nurse. The client says, Why dont you people talk to each other and quit asking the same things over and over? The best response of the nurse is:

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. response.

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

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

Global Rationale: Page Reference: 183-184

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Describe important aspects of the interview setting.

Question 9

Type: MCSA

The nurse makes this entry in the clients chart: Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. However, is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse. This is an example of which method of data collection?

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: Page Reference: 186

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Identify three methods of data collection, and give examples of how each is useful.

Question 10

Type: MCSA

A nurse has worked in the trauma critical care area for several years. Which of the following noises 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-workers 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 co-workers discuss other clients on the unit is helpful in case the nurse has to attend to any one of them.

Global Rationale: Page Reference: 188

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

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

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. Family is at bedside.

Choice 2. The IV pump is running on battery.

Choice 3. ECG monitor shows tachycardia.

Choice 4. 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 a objective cardiac symptom

Rationale 4: Indicates a subjective symptom

Rationale 5: Indicates a possible cause of clients symptoms

Global Rationale: Page Reference: 186

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Identify the purpose of assessing.

Question 12

Type: MCSA

During an initial interview, the client makes this statement: I dont understand why I have to have surgery, Im really not that sick or in pain right now. The nurses best response is:

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: Page Reference: 186-187

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.

Question 13

Type: MCSA

The nurse is taking a health history from a client who has complications from chronic asthma. Which of the following is an example of an open-ended question?

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: Page Reference: 187

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 08 Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.

Question 14

Type: MCSA

Wanting to know more about the clients pain experience, the nurse continues to explore different questioning techniques. Which of the following is the best example of an open-ended question 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: Page Reference: 187

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 08 Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.

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, the nurse should:

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: Page Reference: 188

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Describe important aspects of the interview setting.

Question 16

Type: MCSA

A client comes into the emergency department with a non-life-threatening wound to the hand that will require stitches. The department is quite busy with other clients, their families, and other people in the waiting room. The best way for the nurse to conduct an interview with this client is to:

1. Have the client wait until the department quiets down, since 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: 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. Merely making sure the clients back is to the rest of the room is not as acceptable. Having the client wait may cause an unnecessary delay in treatment.

Rationale 2: 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. Merely making sure the clients back is to the rest of the room is not as acceptable. Having the client wait 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. Merely making sure the clients back is to the rest of the room is not as acceptable. Having the client wait may cause an unnecessary delay in treatment.

Rationale 4: 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. Merely making sure the clients back is to the rest of the room is not as acceptable. Having the client wait may cause an unnecessary delay in treatment.

Global Rationale: Page Reference: 188

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Compare directive and nondirective approaches to interviewing.

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. After the client has been oriented to where the bathroom and nurse call light are, the nurse should start the interview process. In this situation, the nurse may have to pace the interview according to the clients comfort level. The nurse will also have to select focused questions and get information in a quick manner since the client is acutely ill. Medication may affect the clients ability to think clearly, so again, getting as much information quickly is key here.

Rationale 2: Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal. After the client has been oriented to where the bathroom and nurse call light are, the nurse should start the interview process. In this situation, the nurse may have to pace the interview according to the clients comfort level. The nurse will also have to select focused questions and get information in a quick manner since the client is acutely ill. Medication may affect the clients ability to think clearly, so again, getting as much information quickly is key here.

Rationale 3: Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal. After the client has been oriented to where the bathroom and nurse call light are, the nurse should start the interview process. In this situation, the nurse may have to pace the interview according to the clients comfort level. The nurse will also have to select focused questions and get information in a quick manner since the client is acutely ill. Medication may affect the clients ability to think clearly, so again, getting as much information quickly is key here.

Rationale 4: Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal. After the client has been oriented to where the bathroom and nurse call light are, the nurse should start the interview process. In this situation, the nurse may have to pace the interview according to the clients comfort level. The nurse will also have to select focused questions and get information in a quick manner since the client is acutely ill. Medication may affect the clients ability to think clearly, so again, getting as much information quickly is key here.

Global Rationale: Page Reference: 188

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Describe important aspects of the interview setting.

Question 18

Type: MCSA

A nurse has been assigned a new client who cannot speak English. In order that the client receives accurate information, the nurse should:

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: Live translation is preferred since 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. 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 since 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. 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 3: Live translation is preferred since 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. 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: Live translation is preferred since 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. 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.

Global Rationale: Page Reference: 188

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Identify three methods of data collection, and give examples of how each is useful.

Question 19

Type: MCSA

A nursing student is meeting an assigned client for the first time. In order to begin the establishment of rapport, the best statement by the student is:

1. Hello, Im your nursing student and Ill be helping to take care of you today.

2. Youre lucky, you have students and nurses taking care of you today.

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

4. Hi. If you need anything, either your nurse or I will get it for you.

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. Telling a hospitalized client he or she is lucky is probably not the best therapeutic comment. Making introductions, especially offering the use of name, is especially good in establishing rapport.

Rationale 2: 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. Telling a hospitalized client he or she is lucky is probably not the best therapeutic comment. Making introductions, especially offering the use of name, is especially good in establishing rapport.

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. Telling a hospitalized client he or she is lucky is probably not the best therapeutic comment. Making introductions, especially offering the use of name, is especially good in establishing rapport.

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. Telling a hospitalized client he or she is lucky is probably not the best therapeutic comment. Making introductions, especially offering the use of name, is especially good in establishing rapport.

Global Rationale: Page Reference: 187

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Identify three methods of data collection, and give examples of how each is useful.

Question 20

Type: MCSA

The nurse has just completed an admission interview with a new client. Which response by the nurse is an example of a remark used during the closing phase of the interview?

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. The other options are what would be part of the body of the interviewquestions designed to gather the most information about the situation.

Rationale 2: 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. The other options are what would be part of the body of the interviewquestions designed to gather the most information about the situation.

Rationale 3: 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. The other options are what would be part of the body of the interviewquestions designed to gather the most information about the situation.

Rationale 4: 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. The other options are what would be part of the body of the interviewquestions designed to gather the most information about the situation.

Global Rationale: Page Reference: 189

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 06 Identify three methods of data collection, and give examples of how each is useful.

Question 21

Type: MCSA

During an assessment interview, the nurse understands that the client has decided not to take the physicians advice about an elective surgical procedure. The client shares that this is just not part of what I have in mind for my lifes goals. This would fall into which of Gordons functional health patterns?

1. Cognitive/perceptual pattern

2. Coping/stress-tolerance pattern

3. Health-perception/health-management pattern

4. Value/belief pattern

Correct Answer: 4

Rationale 1: 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. Cognitive perceptual patterns describe sensory-perceptual and cognitive patterns. Coping/stress-tolerance patterns describe the clients general coping pattern and the effectiveness of the patterns in terms of stress tolerance. Health-perception/health-management pattern describes the clients perceived pattern of health and well-being and how health is managed.

Rationale 2: 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. Cognitive perceptual patterns describe sensory-perceptual and cognitive patterns. Coping/stress-tolerance patterns describe the clients general coping pattern and the effectiveness of the patterns in terms of stress tolerance. Health-perception/health-management pattern describes the clients perceived pattern of health and well-being and how health is managed.

Rationale 3: 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. Cognitive perceptual patterns describe sensory-perceptual and cognitive patterns. Coping/stress-tolerance patterns describe the clients general coping pattern and the effectiveness of the patterns in terms of stress tolerance. 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. Cognitive perceptual patterns describe sensory-perceptual and cognitive patterns. Coping/stress-tolerance patterns describe the clients general coping pattern and the effectiveness of the patterns in terms of stress tolerance. Health-perception/health-management pattern describes the clients perceived pattern of health and well-being and how health is managed.

Global Rationale: Page Reference: 193

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

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

Question 22

Type: MCSA

A client comes to the emergency department with injuries to her upper shoulders and back area. When questioned about how the injuries occurred, the client becomes less talkative and states that she fell. The client has a history of frequent ED visits, always with believable excuses about how her injuries occurred. The nurse begins to suspect that this client is a victim of abuse. This is an example of the nurse making which of the following?

1. Observation of cues

2. Validation

3. Inference

4. Judgment

Correct Answer: 3

Rationale 1: 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. Validation is the act of double-checking or verifying data to confirm that they are accurate and factual. Judgment is not part of validation.

Rationale 2: 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. Validation is the act of double-checking or verifying data to confirm that they are accurate and factual. Judgment is not part of validation.

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. Validation is the act of double-checking or verifying data to confirm that they are accurate and factual. Judgment is not part of validation.

Rationale 4: 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. Validation is the act of double-checking or verifying data to confirm that they are accurate and factual. Judgment is not part of validation.

Global Rationale: Page Reference: 195

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 07 Compare directive and nondirective approaches to interviewing.

Question 23

Type: MCSA

A nursing student is learning how to implement the nursing process in the clinical area. The purpose of the diagnosis phase includes which of the following?

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. Developing a plan and specifying goals and outcomes is part of the planning phase.

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. Developing a plan and specifying goals and outcomes is part of the planning phase.

Rationale 3: 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. Developing a plan and specifying goals and outcomes is part of the planning phase.

Rationale 4: 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. Developing a plan and 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. Developing a plan and specifying goals and outcomes is part of the planning phase.

Global Rationale: Page Reference: 181-182

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 01 Describe the phases of the nursing process.

Question 24

Type: MCSA

The nurse makes the decision to look at alternatives for wound care with a client who has a stasis ulcer that has been treated over the past 2 weeks. The nurse was hopeful to see some improvement by this time. This represents which phase of the nursing process?

1. Diagnosis

2. Implementation

3. Evaluation

4. Assessment

Correct Answer: 3

Rationale 1: 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. Diagnosis is problem identification. Implementation is carrying out (or delegating) the planned nursing interventions. Wound care would be the implementation of this particular case. Assessment is collecting and organizing data.

Rationale 2: 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. Diagnosis is problem identification. Implementation is carrying out (or delegating) the planned nursing interventions. Wound care would be the implementation of this particular case. Assessment is collecting and organizing data.

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. Diagnosis is problem identification. Implementation is carrying out (or delegating) the planned nursing interventions. Wound care would be the implementation of this particular case. Assessment is collecting and organizing data.

Rationale 4: 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. Diagnosis is problem identification. Implementation is carrying out (or delegating) the planned nursing interventions. Wound care would be the implementation of this particular case. Assessment is collecting and organizing data.

Global Rationale: Page Reference: 181-182

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 01 Describe the phases of the nursing process.

Question 25

Type: MCSA

A nurse is working in the operating room with a client just prior to the procedure. While setting up for the procedure, the nurse notices that the client has become unresponsive and respirations have become shallow. What type of assessment would be necessary in this situation?

1. Initial assessment

2. Problem-focused assessment

3. Emergency assessment

4. Time-lapsed assessment

Correct Answer: 3

Rationale 1: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems. Initial assessment is performed within a specific time after admission to a health care agency. Problem-focused assessment is an ongoing process integrated with nursing care. Time-lapsed assessment occurs several months after the initial assessment to compare the clients current status to baseline data previously obtained.

Rationale 2: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems. Initial assessment is performed within a specific time after admission to a health care agency. Problem-focused assessment is an ongoing process integrated with nursing care. Time-lapsed assessment occurs several months after the initial assessment to compare the clients current status to baseline data previously obtained.

Rationale 3: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems. Initial assessment is performed within a specific time after admission to a health care agency. Problem-focused assessment is an ongoing process integrated with nursing care. Time-lapsed assessment occurs several months after the initial assessment to compare the clients current status to baseline data previously obtained.

Rationale 4: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems. Initial assessment is performed within a specific time after admission to a health care agency. Problem-focused assessment is an ongoing process integrated with nursing care. Time-lapsed assessment occurs several months after the initial assessment to compare the clients current status to baseline data previously obtained.

Global Rationale: Page Reference: 183

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Differentiate objective and subjective data and primary and secondary data.

Question 26

Type: MCSA

A nurse has delegated to a nurses aide to obtain vital signs for a newly admitted client. The aide reports the following: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. To validate the data, the best action by the nurse is:

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. Calling the physician and reporting the findings to the charge nurse before they have been validated would be premature. The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated.

Rationale 2: 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. Calling the physician and reporting the findings to the charge nurse before they have been validated would be premature. The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated.

Rationale 3: 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. Calling the physician and reporting the findings to the charge nurse before they have been validated would be premature. The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated.

Rationale 4: 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. Calling the physician and reporting the findings to the charge nurse before they have been validated would be premature. The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated.

Global Rationale: Page Reference: 195

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Differentiate objective and subjective data and primary and secondary data.

Question 27

Type: MCMA

A nurse is performing an initial assessment on a new admission. Which of the following is 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.

Rationale 5: 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 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 the physicians orders for this admission, or discharge instructions.

Global Rationale: Page Reference: 183

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Identify three methods of data collection, and give examples of how each is useful.

Question 28

Type: MCMA

A nurse implementing effective communication guidelines during an assessment interview when:

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

Rationale 1: Communication guidelines for a therapeutic interview would include establishing eye contact, since doing so shows interest and focus on the client.

Rationale 2: Communication guidelines for a therapeutic interview would not include the avoidance of silence, since silence has therapeutic value.

Rationale 3: Communication guidelines for a therapeutic interview would not include personal experiences or opinions, since they can be viewed as a form of pressure by the client.

Rationale 4: Communication guidelines for a therapeutic interview would include sitting at the clients eye level, since doing so helps create a sense of equality between the nurse and client.

Rationale 5: Communication guidelines for a therapeutic interview would include assuming a relaxed posture, since doing so conveys a non-threatening environment.

Global Rationale: Page Reference: 189

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Describe important aspects of the interview setting.

Question 29

Type: MCMA

Nursing activities that represent the various characteristics of the nursing process includes the nurses:

Standard Text: Select all that apply.

1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature.

2. Advocating for a client who is mentally incapable of expressing her needs.

3. Deciding to increase a clients nasal oxygen based on his current pulse oxygenation levels.

4. Documenting all clients pain level responses after the administration of pain medication.

5. Attending in-services on a new hydraulic lift to be used to support safe client care.

Correct Answer: 1,2,3,4

Rationale 1: The nursing process has distinctive characteristics that include being dynamic so as to respond to clients ever-changing needs.

Rationale 2: The nursing process has distinctive characteristics that include being client-centered, as evidenced by actions such as acting as the clients advocate.

Rationale 3: The nursing process has distinctive characteristics that include decision making that enables the nurse to respond to the changing health status of the client.

Rationale 4: The nursing process has distinctive characteristics that include universal applicability of care.

Rationale 5: This is a nursing responsibility but not necessarily a characteristic of the nursing process.

Global Rationale: Page Reference: 178

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Identify major characteristics of the nursing process.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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