ramont2e rev tif ch06

8/20/2019 Ramont2e Rev TIF Ch06

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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank

Chapter 6Question 1

Type: MCSA

Which of the following collected by the nurse is subjective data?

1. Clubbing fingertips

2. Avoidance of eye contact

. Nausea

!. Vomiting

Corre"t #ns$er:

Rationa%e 1! Subjective data are data that the client e"periences that are not visible or measurable by the nurse#

Clubbing fingertips$ avoidance of eye contact$ and vomiting are concrete and visible to the nurse$ so they would

be considered objective data#

Rationa%e 2! Subjective data are data that the client e"periences that are not visible or measurable by the nurse#

Clubbing fingertips$ avoidance of eye contact$ and vomiting are concrete and visible to the nurse$ so they would


Rationa%e ! Subjective data are data that the client e"periences that are not visible or measurable by the nurse#Clubbing fingertips$ avoidance of eye contact$ and vomiting are concrete and visible to the nurse$ so they would


Rationa%e !! Subjective data are data that the client e"periences that are not visible or measurable by the nurse#

Clubbing fingertips$ avoidance of eye contact$ and vomiting are concrete and visible to the nurse$ so they would be considered objective data#

&%o'a% Rationa%e:

Cogniti(e )e(e%: Applying

C%ient Need: Safe %ffective Care %nvironmentC%ient Need *u':

Nursing+ntegrated Con"epts: Nursing &rocess! Assessment

)earning -ut"ome: 'ifferentiate objective and subjective data$ and primary and secondary data#

Question 2

Type: MCSA

(amont$ Niedringhous$ Comprehensive Nursing Care )nd %dition *pdate +est ,an-

Copyright )./) by &earson %ducation$ 0nc#



+he nurse is reinforcing teaching for an adolescent who is being discharged to home on a special diet# Which of

the following best describes the step of the nursing process performed by the nurse when teaching the client abou

diet?

1. Assessment

2. 0mplementation

. &lanning

!. %valuating

Corre"t #ns$er: )

Rationa%e 1! +eaching is part of implementation because it is an action or behavior performed by the nurse to

improve the client1s health status# Assessment is done to collect data in order to determine client problems and

needs$ which had to have been done already in order to determine that the client re2uires diet teaching# &lanning i

conducted before implementing to determine specific teaching needs and to establish goals of care# %valuating isdone after teaching is completed to determine if the goals and outcomes set during the planning stage were met#

Rationa%e 2! +eaching is part of implementation because it is an action or behavior performed by the nurse to

improve the client1s health status# Assessment is done to collect data in order to determine client problems andneeds$ which had to have been done already in order to determine that the client re2uires diet teaching# &lanning i

conducted before implementing to determine specific teaching needs and to establish goals of care# %valuating is

done after teaching is completed to determine if the goals and outcomes set during the planning stage were met#

Rationa%e ! +eaching is part of implementation because it is an action or behavior performed by the nurse toimprove the client1s health status# Assessment is done to collect data in order to determine client problems and

needs$ which had to have been done already in order to determine that the client re2uires diet teaching# &lanning i

conducted before implementing to determine specific teaching needs and to establish goals of care# %valuating isdone after teaching is completed to determine if the goals and outcomes set during the planning stage were met#

Rationa%e !! +eaching is part of implementation because it is an action or behavior performed by the nurse to

improve the client1s health status# Assessment is done to collect data in order to determine client problems and

needs$ which had to have been done already in order to determine that the client re2uires diet teaching# &lanning iconducted before implementing to determine specific teaching needs and to establish goals of care# %valuating is

done after teaching is completed to determine if the goals and outcomes set during the planning stage were met#

&%o'a% Rationa%e:


C%ient Need: Safe %ffective Care %nvironment

C%ient Need *u':

Nursing+ntegrated Con"epts: Nursing &rocess! 0mplementation

)earning -ut"ome: 'escribe the components of the nursing process#

Question





Type: MCSA

Which of the following actions would the nurse perform when collecting data about a client to assist with

completion of the admission assessment form?

1. (eview the physician1s orders for the medical diagnosis#

2. %"amine the client1s financial sheet to determine method of payment#

. 'ocument the collected data on the medical record#

!. Spea- with the client1s spouse and children to learn more about the client#

Corre"t #ns$er: 3

Rationa%e 1! 0nterviewing is a techni2ue used in assessment# 0nterviewing the client1s family gathers secondary

data$ yields subjective data$ and can be very helpful# (eviewing the physician order sheet is not part of the proces

of data collection$ although it will yield important information$ and is indicated as part of the admission process#'etermining how the client will pay is not part of the nursing process$ and generally is irrelevant to the nurse#

'ocumentation is an essential part of providing nursing care$ and all assessment data should be documented$ but

is considered an implementation#

Rationa%e 2! 0nterviewing is a techni2ue used in assessment# 0nterviewing the client1s family gathers secondary


of data collection$ although it will yield important information$ and is indicated as part of the admission process#

'etermining how the client will pay is not part of the nursing process$ and generally is irrelevant to the nurse#'ocumentation is an essential part of providing nursing care$ and all assessment data should be documented$ but


Rationa%e ! 0nterviewing is a techni2ue used in assessment# 0nterviewing the client1s family gathers secondary

data$ yields subjective data$ and can be very helpful# (eviewing the physician order sheet is not part of the procesof data collection$ although it will yield important information$ and is indicated as part of the admission process#

'etermining how the client will pay is not part of the nursing process$ and generally is irrelevant to the nurse#

'ocumentation is an essential part of providing nursing care$ and all assessment data should be documented$ but is considered an implementation#

Rationa%e !! 0nterviewing is a techni2ue used in assessment# 0nterviewing the client1s family gathers secondary


of data collection$ although it will yield important information$ and is indicated as part of the admission process#'etermining how the client will pay is not part of the nursing process$ and generally is irrelevant to the nurse#

'ocumentation is an essential part of providing nursing care$ and all assessment data should be documented$ but


&%o'a% Rationa%e:



C%ient Need *u':






)earning -ut"ome: 'escribe the role of the 4&N54VN in the assessment process#

Question !

Type: MCSA

+he unlicensed assistive personnel says to the nurse$ 60 always hear the nurses tal-ing about the nursing process#

Why is the nursing process so important to nurses?6 +he nurse1s best response would include which of the

following points?

1. 6+he facility re2uires that we use the nursing process to ta-e care of clients#6

2. 6Nurses use the nursing process as a problem7solving method to provide better client care#6

. 6+he nursing process is used to ma-e sure we don1t forget something#6

!. 6+he nursing process is mandated for use by the state board of nursing#6

Corre"t #ns$er: )

Rationa%e 1! +he nursing process is a problem solving approach to nursing care that ta-es the critical thin-inginvolved in the care of the client through a step by step process#

Rationa%e 2! +he nursing process is a problem solving approach to nursing care that ta-es the critical thin-ing

involved in the care of the client through a step by step process#

Rationa%e ! +he nursing process is a problem solving approach to nursing care that ta-es the critical thin-ing


Rationa%e !! +he nursing process is a problem solving approach to nursing care that ta-es the critical thin-ing


&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: 0dentify essential characteristics of the nursing process#

Question

Type: MCSA

Which of the following would be considered essential data to gather upon first admitting a client to the nursing

unit?





1. Allergies

2. 8ccupation

. 9ood preferences

!. &revious e"perience with hospitali:ation

Corre"t #ns$er: /

Rationa%e 1! While all of this information can improve client care$ the most urgent information to obtain about

clients upon admission to the unit is their allergies$ because e"posure to an allergen$ whether medication$ food$ orother substance$ could negatively impact client outcomes#

Rationa%e 2! While all of this information can improve client care$ the most urgent information to obtain about

clients upon admission to the unit is their allergies$ because e"posure to an allergen$ whether medication$ food$ or

other substance$ could negatively impact client outcomes#

Rationa%e ! While all of this information can improve client care$ the most urgent information to obtain aboutclients upon admission to the unit is their allergies$ because e"posure to an allergen$ whether medication$ food$ or

other substance$ could negatively impact client outcomes#

Rationa%e !! While all of this information can improve client care$ the most urgent information to obtain about

clients upon admission to the unit is their allergies$ because e"posure to an allergen$ whether medication$ food$ orother substance$ could negatively impact client outcomes#

&%o'a% Rationa%e:


C%ient Need: &hysiological 0ntegrityC%ient Need *u':


)earning -ut"ome: 'efine the purpose of collecting data and how the data will be used#

Question 6

Type: MCSA

+he nurse uses information gathered during the assessment phase to benefit client care in what way?

1. +o schedule a client1s care

2. +o contribute to the development of an individuali:ed plan of care

. +o determine the cause of the client1s health problem

!. +o determine what medications should be prescribed





Corre"t #ns$er: )

Rationa%e 1! ,aseline assessments assist the nurse to develop an individuali:ed plan of care specifically aimed atthat client1s needs# Clients1 care can be scheduled with consideration to clients1 preferences$ but is also determined

by client needs# Cause of health problems and medications are the provider1s responsibility#

Rationa%e 2! ,aseline assessments assist the nurse to develop an individuali:ed plan of care specifically aimed at

that client1s needs# Clients1 care can be scheduled with consideration to clients1 preferences$ but is also determined by client needs# Cause of health problems and medications are the provider1s responsibility#

Rationa%e ! ,aseline assessments assist the nurse to develop an individuali:ed plan of care specifically aimed at

that client1s needs# Clients1 care can be scheduled with consideration to clients1 preferences$ but is also determined


Rationa%e !! ,aseline assessments assist the nurse to develop an individuali:ed plan of care specifically aimed at

that client1s needs# Clients1 care can be scheduled with consideration to clients1 preferences$ but is also determined


&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: 'efine the purpose of collecting data and how the data will be used#

Question /

Type: MCSA

+he nurse is collecting data on a client# Which of the following data collected by the student is an e"ample of

primary data?

1. (eview of the medical record

2. (eview of laboratory results

. 4istening to morning report

!. 0nformation obtained from client

Corre"t #ns$er: 3

Rationa%e 1! 0nformation obtained from the client is considered primary data# All other sources of data are

considered secondary#

Rationa%e 2! 0nformation obtained from the client is considered primary data# All other sources of data are






Rationa%e ! 0nformation obtained from the client is considered primary data# All other sources of data areconsidered secondary#

Rationa%e !! 0nformation obtained from the client is considered primary data# All other sources of data are


&%o'a% Rationa%e:



C%ient Need *u':



Question 0

Type: MCSA

+he nurse is collecting data on a client at the beginning of the shift# Which of the following would be consideredobjective data?

1. +he client relates major stressors in his life#

2. +he client relates past reactions to +ylenol#

. +he client1s vital signs#

!. +he client states his religious beliefs#

Corre"t #ns$er:

Rationa%e 1! 8bjective data are data that can be observed# Vital signs are evident to the nurse# Stressors$ reaction

to medications in the past$ and religious beliefs are e"amples of subjective data# +he nurse cannot see any of thes

things$ and must rely on the client1s perception of them#

Rationa%e 2! 8bjective data are data that can be observed# Vital signs are evident to the nurse# Stressors$ reactionto medications in the past$ and religious beliefs are e"amples of subjective data# +he nurse cannot see any of thes


Rationa%e ! 8bjective data are data that can be observed# Vital signs are evident to the nurse# Stressors$ reaction

to medications in the past$ and religious beliefs are e"amples of subjective data# +he nurse cannot see any of thesthings$ and must rely on the client1s perception of them#

Rationa%e !! 8bjective data are data that can be observed# Vital signs are evident to the nurse# Stressors$ reaction

to medications in the past$ and religious beliefs are e"amples of subjective data# +he nurse cannot see any of thes


&%o'a% Rationa%e:







C%ient Need *u':



Question

Type: MCSA

+he nurse is teaching a group of ;7year7old diabetics how to use and clean their glucose meters# After

demonstrating the techni2ue$ the children perform a return demonstration# Which of the following methods of dat

collection is the nurse using to determine if the clients have mastered the s-ill?

1. %valuation

2. %"amination

. &lanning

!. 8bservation

Corre"t #ns$er: 3

Rationa%e 1! +he student is observing the techni2ue of the clients# +he observed information is then processed inorder to evaluate the effectiveness of the teaching# %valuation and planning are two steps in the nursing process#

%"amination is a method of collecting physical data$ such as listening to breathe sounds#

Rationa%e 2! +he student is observing the techni2ue of the clients# +he observed information is then processed inorder to evaluate the effectiveness of the teaching# %valuation and planning are two steps in the nursing process#%"amination is a method of collecting physical data$ such as listening to breathe sounds#

Rationa%e ! +he student is observing the techni2ue of the clients# +he observed information is then processed in

order to evaluate the effectiveness of the teaching# %valuation and planning are two steps in the nursing process#


Rationa%e !! +he student is observing the techni2ue of the clients# +he observed information is then processed in

order to evaluate the effectiveness of the teaching# %valuation and planning are two steps in the nursing process#


&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: 0dentify three methods of data collection and give e"amples of how each is useful#





Question 1

Type: MCSA

Which of the following would e"plain the need for a two7part nursing diagnosis?

1. +his client has only two nursing diagnoses#

2. +he client1s problem is caused by two different health issues#

. +he client is at ris- for developing a problem#

!. +he client has an actual nursing problem#

Corre"t #ns$er:

Rationa%e 1! A two7part nursing diagnosis is used to identify a potential problem and the reason the client is at

ris-$ such as 0nfection$ ris- for secondary to suppressed immune system# An actual problem statement has three parts that state the problem$ the cause of the problem$ and the signs and symptoms that validate the problem#

Rationa%e 2! A two7part nursing diagnosis is used to identify a potential problem and the reason the client is atris-$ such as 0nfection$ ris- for secondary to suppressed immune system# An actual problem statement has three

parts that state the problem$ the cause of the problem$ and the signs and symptoms that validate the problem#

Rationa%e ! A two7part nursing diagnosis is used to identify a potential problem and the reason the client is at

ris-$ such as 0nfection$ ris- for secondary to suppressed immune system# An actual problem statement has three parts that state the problem$ the cause of the problem$ and the signs and symptoms that validate the problem#

Rationa%e !! A two7part nursing diagnosis is used to identify a potential problem and the reason the client is atris-$ such as 0nfection$ ris- for secondary to suppressed immune system# An actual problem statement has three

parts that state the problem$ the cause of the problem$ and the signs and symptoms that validate the problem#

&%o'a% Rationa%e:



C%ient Need *u':

Nursing+ntegrated Con"epts: Nursing &rocess! 'iagnosis

)earning -ut"ome: 'escribe the importance and the elements of nursing diagnoses#

Question 11

Type: MCSA

+he 4&N54VN is participating in a client care conference of an assigned client# Which of the following is the best

way for the 4&N54VN to assist with planning for this client1s care?

1. 4isten to information presented by the team#





2. +ell the participants about observations made while bathing the client#

. Suggest goals for the client1s safety#

!. Suggest nursing diagnoses appropriate for the client#

Corre"t #ns$er:

Rationa%e 1! +he 4&N54VN can best participate in the conference by suggesting goals for client based on

firsthand -nowledge of the client1s needs and preferences# 4istening to information is polite$ but does not

contribute to planning care# +he (N is responsible for creating appropriate nursing diagnoses# 0nformation aboutobservations made during client care should be documented on the chart and available to the team#

Rationa%e 2! +he 4&N54VN can best participate in the conference by suggesting goals for client based on

firsthand -nowledge of the client1s needs and preferences# 4istening to information is polite$ but does not


Rationa%e ! +he 4&N54VN can best participate in the conference by suggesting goals for client based onfirsthand -nowledge of the client1s needs and preferences# 4istening to information is polite$ but does not


Rationa%e !! +he 4&N54VN can best participate in the conference by suggesting goals for client based on

firsthand -nowledge of the client1s needs and preferences# 4istening to information is polite$ but does notcontribute to planning care# +he (N is responsible for creating appropriate nursing diagnoses# 0nformation about

observations made during client care should be documented on the chart and available to the team#

&%o'a% Rationa%e:



C%ient Need *u':

Nursing+ntegrated Con"epts: Nursing &rocess! &lanning

)earning -ut"ome: 'iscuss the planning step of the nursing process#

Question 12

Type: MCSA

Which of the following would be an appropriate nursing goal?

1. +he client will raise her right arm to shoulder height by 9riday#

2. +he client will begin to use her right arm#

. +he client will not complain of pain in the right arm#





!. +he client should not injure the right arm#

Corre"t #ns$er: /

Rationa%e 1! &art of the planning process includes setting goals for the client that are specific$ timed$ and

measurable# The client will begin to use the right arm does not offer a time frame or specify how the arm will be

used$ which would ma-e evaluation of progress impossible# 4ac- of complaints of pain in the arm is not

indicative the client doesn1t have pain$ only that no spontaneous reports are made# 4ac- of injury is toononspecific$ and would not be the best choice of goals#

Rationa%e 2! &art of the planning process includes setting goals for the client that are specific$ timed$ and


used$ which would ma-e evaluation of progress impossible# 4ac- of complaints of pain in the arm is notindicative the client doesn1t have pain$ only that no spontaneous reports are made# 4ac- of injury is too

nonspecific$ and would not be the best choice of goals#

Rationa%e ! &art of the planning process includes setting goals for the client that are specific$ timed$ andmeasurable# The client will begin to use the right arm does not offer a time frame or specify how the arm will be

used$ which would ma-e evaluation of progress impossible# 4ac- of complaints of pain in the arm is notindicative the client doesn1t have pain$ only that no spontaneous reports are made# 4ac- of injury is too

nonspecific$ and would not be the best choice of goals#

Rationa%e !! &art of the planning process includes setting goals for the client that are specific$ timed$ and


used$ which would ma-e evaluation of progress impossible# 4ac- of complaints of pain in the arm is not

indicative the client doesn1t have pain$ only that no spontaneous reports are made# 4ac- of injury is toononspecific$ and would not be the best choice of goals#

&%o'a% Rationa%e:


C%ient Need: &hysiological 0ntegrity

C%ient Need *u':


)earning -ut"ome: 'iscuss the planning step of the nursing process#

Question 1

Type: MCSA

Which of the following is a nursing implementation?

1. Auscultation of bowel sounds

2. &rovide s-in care and turn the client every two hours#

. (eport that the client is performing more of her own A'4s#





!. 'ocumentation of redness on the client1s elbow

Corre"t #ns$er: )

Rationa%e 1! &roviding s-in care and turning the client are implementation activities# Auscultation and

documentation of redness are part of the assessment process# (eporting that the client is performing more A'4s i

an evaluation statement#

Rationa%e 2! &roviding s-in care and turning the client are implementation activities# Auscultation anddocumentation of redness are part of the assessment process# (eporting that the client is performing more A'4s i


Rationa%e ! &roviding s-in care and turning the client are implementation activities# Auscultation and

documentation of redness are part of the assessment process# (eporting that the client is performing more A'4s ian evaluation statement#

Rationa%e !! &roviding s-in care and turning the client are implementation activities# Auscultation and

documentation of redness are part of the assessment process# (eporting that the client is performing more A'4s i


&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome: 'iscuss the activities of the implementing phase#

Question 1!

Type: MCSA

+he nurse assesses the client and finds that the client1s temperature is /.)<9# +he nurse administers +ylenol =>.

mg$ as ordered by the physician$ and repeats the temperature measurement in one hour for what purpose?

1. Assessment of the temperature

2. 'iagnosing that the client still has a fever

. %valuating the effectiveness of the medication

!. &lanning to ta-e the temperature in one hour

Corre"t #ns$er:

Rationa%e 1! (eta-ing the temperature after administering the +ylenol is reassessing or evaluating the

effectiveness of the treatment# While ta-ing a temperature is part of an assessment$ in this instance$ the nurse is





evaluating the efficacy of the +ylenol in treating the client1s temperature# 'iagnosing a fever is not a diagnosis$ bua statement of fact# &lanning involves setting goals and outcomes related to the problem of hyperthermia#

Rationa%e 2! (eta-ing the temperature after administering the +ylenol is reassessing or evaluating the

effectiveness of the treatment# While ta-ing a temperature is part of an assessment$ in this instance$ the nurse is

evaluating the efficacy of the +ylenol in treating the client1s temperature# 'iagnosing a fever is not a diagnosis$ bua statement of fact# &lanning involves setting goals and outcomes related to the problem of hyperthermia#

Rationa%e ! (eta-ing the temperature after administering the +ylenol is reassessing or evaluating the

effectiveness of the treatment# While ta-ing a temperature is part of an assessment$ in this instance$ the nurse isevaluating the efficacy of the +ylenol in treating the client1s temperature# 'iagnosing a fever is not a diagnosis$ bu

a statement of fact# &lanning involves setting goals and outcomes related to the problem of hyperthermia#

Rationa%e !! (eta-ing the temperature after administering the +ylenol is reassessing or evaluating the

effectiveness of the treatment# While ta-ing a temperature is part of an assessment$ in this instance$ the nurse isevaluating the efficacy of the +ylenol in treating the client1s temperature# 'iagnosing a fever is not a diagnosis$ bu

a statement of fact# &lanning involves setting goals and outcomes related to the problem of hyperthermia#

&%o'a% Rationa%e:



C%ient Need *u':

Nursing+ntegrated Con"epts: Nursing &rocess! %valuation

)earning -ut"ome: %"plain the value of evaluating and how evaluating relates to other phases of the nursing

process#

Question 1

Type: MCSA

+he nurse is caring for an adolescent who complains of a headache# +he nurse dims the light in the room$

administers the ordered pain medication$ and provides the adolescent with a caffeinated soda# Which of the

following is the correct method of evaluating the effectiveness of this intervention?

1. +a-e the client1s vital signs#

2. As- the parents if the client is feeling better#

. 8bserve the adolescent for signs of pain#

!. As- the adolescent to rate the pain in one hour#

Corre"t #ns$er: 3

Rationa%e 1! &ain is a subjective symptom that only the client can describe# As-ing the parents to report theclient1s status and observing for signs of pain would yield secondary data$ while as-ing the client directly provide

more valuable information to evaluate outcome#





Rationa%e 2! &ain is a subjective symptom that only the client can describe# As-ing the parents to report theclient1s status and observing for signs of pain would yield secondary data$ while as-ing the client directly provide

more valuable information to evaluate outcome#

Rationa%e ! &ain is a subjective symptom that only the client can describe# As-ing the parents to report the

client1s status and observing for signs of pain would yield secondary data$ while as-ing the client directly providemore valuable information to evaluate outcome#

Rationa%e !! &ain is a subjective symptom that only the client can describe# As-ing the parents to report the

client1s status and observing for signs of pain would yield secondary data$ while as-ing the client directly providemore valuable information to evaluate outcome#

&%o'a% Rationa%e:

Cogniti(e )e(e%: Analy:ing


C%ient Need *u':


)earning -ut"ome: %"plain the value of evaluating and how evaluating relates to other phases of the nursing

process#

Question 16

Type: MCMA

+he nursing student is preparing a report on the nursing process for class$ and can best e"plain the purpose of the

nursing process with which of the following statements? Select all that apply#

*tandard Te3t: Select all that apply#

1. +each the nurse how to assess the client#

2. 'etermine actual or potential client problems#

. &rovide a framewor- for policies of nursing#

!. %stablish plans to meet client needs#

. 0dentify the client1s health status#

Corre"t #ns$er: )$3$>

Rationa%e 1! +he purpose of the nursing process is to identify the current health status of the client$ determineactual and potential health problems$ establish plans to meet client needs$ implement those plans$ and evaluate the

client response to nursing care# Assessment is one of the steps of the nursing process# Writing policies might

follow the nursing process but is not the purpose of the nursing process#





Rationa%e 2! +he purpose of the nursing process is to identify the current health status of the client$ determineactual and potential health problems$ establish plans to meet client needs$ implement those plans$ and evaluate the



Rationa%e ! +he purpose of the nursing process is to identify the current health status of the client$ determineactual and potential health problems$ establish plans to meet client needs$ implement those plans$ and evaluate the

client response to nursing care# Assessment is one of the steps of the nursing process# Writing policies mightfollow the nursing process but is not the purpose of the nursing process#

Rationa%e !! +he purpose of the nursing process is to identify the current health status of the client$ determine

actual and potential health problems$ establish plans to meet client needs$ implement those plans$ and evaluate the



Rationa%e ! +he purpose of the nursing process is to identify the current health status of the client$ determine

actual and potential health problems$ establish plans to meet client needs$ implement those plans$ and evaluate the



&%o'a% Rationa%e:


C%ient Need:

C%ient Need *u':

Nursing+ntegrated Con"epts:


Question 1/

Type: MCMA

0n which of the following ways does the 4&N54VN contribute to the nursing process? Select all that apply#


1. Stoc-ing the client1s room with needed supplies

2. iving the client a bath and bac- rub

. Changing the client1s linen

!. 'ocumenting the client response to +ylenol given for a fever

. Notifying the (N of deteriorating vital signs

Corre"t #ns$er: 3$>





Rationa%e 1! +he 4&N54VN contributes to the nursing process by documenting and reporting client response totreatment# +he other options are necessary routine care that contribute to client comfort and care but do not

contribute to the nursing process#

Rationa%e 2! +he 4&N54VN contributes to the nursing process by documenting and reporting client response to

treatment# +he other options are necessary routine care that contribute to client comfort and care but do notcontribute to the nursing process#

Rationa%e ! +he 4&N54VN contributes to the nursing process by documenting and reporting client response to

treatment# +he other options are necessary routine care that contribute to client comfort and care but do notcontribute to the nursing process#

Rationa%e !! +he 4&N54VN contributes to the nursing process by documenting and reporting client response to

treatment# +he other options are necessary routine care that contribute to client comfort and care but do not


Rationa%e ! +he 4&N54VN contributes to the nursing process by documenting and reporting client response totreatment# +he other options are necessary routine care that contribute to client comfort and care but do not


&%o'a% Rationa%e:



C%ient Need *u':



Question 10

Type: MCMA

Characteristics of the nursing process include!


1. 0t is a logical method of providing individuali:ed nursing care

2. Can only be utili:ed by (Ns

. Components include assessing$ diagnosing$ planning$ interventions$ evaluation

!. &rovides a framewor- in which clients can discuss their actual and potential health problems

. Components follow a logical se2uence$ one at a time

Corre"t #ns$er: /$





Rationa%e 1! +he nursing process is a systematic$ logical method of providing individuali:ed nursing care

Rationa%e 2! +he nursing process provides a common way of thin-ing for all nurses

Rationa%e ! Components include assessment$ diagnosing @analysis$ planning$ implementing @intervention$ and

evaluating

Rationa%e !! +he nursing process provides a framewor- in which nurses use their -nowledge and s-ills to e"preshuman caring$ and to help clients with their actual and potential health problems

Rationa%e ! +he components of the nursing process follow a logical se2uence$ but more than one component

may be involved at any one time

&%o'a% Rationa%e:

Cogniti(e )e(e%: *nderstanding


C%ient Need *u':


)earning -ut"ome:

Question 1

Type: MCSA

+he role of the 4&N54VN in the assessment phase of the nursing process is to

1. +o identify client strengths and promote health maintenance

2. Collect data and observe and report client status to the (N

. +o develop an individuali:ed care plan

!. +o observe or measure client responses to nursing interventions

.

Corre"t #ns$er: )

Rationa%e 1! +he role of the 4&N54VN in assessing is to collect data$ observe client status$ report abnormal data

or changes in client condition to the (N

Rationa%e 2! +he role of the 4&N54VN in assessing is to collect data$ observe client status$ report abnormal dataor changes in client condition to the (N

Rationa%e ! +he role of the 4&N54VN in assessing is to collect data$ observe client status$ report abnormal data

or changes in client condition to the (N





Rationa%e !! +he role of the 4&N54VN in assessing is to collect data$ observe client status$ report abnormal dataor changes in client condition to the (N

Rationa%e !

&%o'a% Rationa%e:

Cogniti(e )e(e%: ApplyingC%ient Need: Bealth &romotion and Maintenance

C%ient Need *u':


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Question 2

Type: MCSA

+he 4&N54VN encourages the client to ambulate twice a day# +his is an e"ample of which stage of the nursing

process?

1. Assessment

2. &lanning

. 0mplementation

!. %valuating

.

Corre"t #ns$er:

Rationa%e 1! +his is not an e"ample of assessment#

Rationa%e 2! +he nursing care plan will direct actions#

Rationa%e ! +his is an e"ample of carrying out the plan of care#

Rationa%e !! +his is not an e"ample of evaluating#

Rationa%e !

&%o'a% Rationa%e:



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Question 21

Type: MCSA

After administering pain medication to a postoperative client$ the 4&N54VN returns in . minutes to as- the clien

if relief was obtained# +his is an e"ample of which stage of the nursing process?

1. &lanning

2. Assessing

. %valuation

!. 0mplementing

.

Corre"t #ns$er:

Rationa%e 1! +o observe or measure client response to nursing interventions is a component of the evaluation

process

Rationa%e 2! +o observe or measure client response to nursing interventions is a component of the evaluation process

Rationa%e ! +o observe or measure client response to nursing interventions is a component of the evaluation

process

Rationa%e !! +o observe or measure client response to nursing interventions is a component of the evaluation

process

Rationa%e !

&%o'a% Rationa%e:



C%ient Need *u':

Nursing+ntegrated Con"epts: Nursing &rocess! %valuation)earning -ut"ome:

Question 22

Type: MCSA

+he 4&N54VN contributes to nursing diagnoses by





1. 0dentifying client strengths

2. Naming health problems that can be prevented

. *nderstanding the nursing diagnoses identified by the (N

!. 'eveloping a list of independent nursing interventions

.

Corre"t #ns$er:

Rationa%e 1! 0dentifying client strengths is an (N function

Rationa%e 2! Naming health problems is an (N function

Rationa%e ! *nderstanding the nursing diagnoses as they relate to the clients condition is the role of the4&N54VN

Rationa%e !! +he (N develops a list of collaborative and independent nursing interventions

Rationa%e !

&%o'a% Rationa%e:



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Question 2

Type: MCSA

Nursing assessment focuses on

1. A client1s responses to a health problem

2. +he nursing process

. 'ocumentation

!. +he client1s database

.

Corre"t #ns$er: /





Rationa%e 1! All phases of the nursing process focus on a client1s response to a health problem#

Rationa%e 2! All phases of the nursing process depend on accurate and complete collection of data#

Rationa%e ! 'ocumentation of data is one of four activities in the assessment process#

Rationa%e !! +e client database includes information from many sources and is a result of many assessments#

Rationa%e !

&%o'a% Rationa%e:



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Question 2!

Type: MCMA

+he 4&N54VN understands the four activities involved in assessment include


1. athering information about a client

2. 8rgani:ing data

. 'ocumenting data

!. Measuring responses to nursing interventions

. Validating data

Corre"t #ns$er: /$)$$>

Rationa%e 1! 'ata collection is a systematic process of gathering information about a client#

Rationa%e 2! 8rgani:ing data for easy retrieval can be done by following a nursing health history format#

Rationa%e ! 'ocumenting data in the client record is essential for ongoing evaluation of client condition#

Rationa%e !! Measuring response to nursing interventions is done in the evaluating stage of the nursing process

Rationa%e ! Validating data @proving or supporting data is part of the assessment process





&%o'a% Rationa%e:



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Question 2

Type: MCSA

+he nurse collects which -inds of data when assessing a client?

1. Subjective and primary

2. 8bjective and primary

. Subjective and objective

!. Subjective and secondary

.

Corre"t #ns$er:

Rationa%e 1! Subjective data @symptoms$ conditions that apparent to only the person affected and objective data@signs$ those that can be measured or observed$ are collected by the nurse#

Rationa%e 2! Subjective data @symptoms$ conditions that apparent to only the person affected and objective data@signs$ those that can be measured or observed$ are collected by the nurse#

Rationa%e ! Subjective data @symptoms$ conditions that apparent to only the person affected and objective data

@signs$ those that can be measured or observed$ are collected by the nurse#

Rationa%e !! Subjective data @symptoms$ conditions that apparent to only the person affected and objective data

@signs$ those that can be measured or observed$ are collected by the nurse#

Rationa%e !

&%o'a% Rationa%e:



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Question 26

Type: MCSA

'uring data collection$ the nurse identifies the following as subjective data!

1. 4aughing during interview

2. 60 feel so di::y6

. 6My dressing is bloody6

!. +emperature is /..#)

.

Corre"t #ns$er: )

Rationa%e 1! +he nurse can observe this data$ so it is objective data#

Rationa%e 2! +he nurse cannot observe this data$ so it is subjective data#

Rationa%e ! +he nurse can observe this data so it is objective data#

Rationa%e !! +he nurse can measure this data so it is objective data#

Rationa%e !

&%o'a% Rationa%e:



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Question 2/

Type: MCSA

1.

2.

.

!.

.





Corre"t #ns$er:

Rationa%e 1!

Rationa%e 2!

Rationa%e !

Rationa%e !!

Rationa%e !

&%o'a% Rationa%e:

Cogniti(e )e(e%:

C%ient Need:

C%ient Need *u':


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Question 20

Type: MCMA

When reviewing the client nursing care plan$ the nurse notes the following components in each nursing diagnosis


1. 'iagnostic label

2. 'efining characteristics

. Dualifiers

!. %tiology

. Duestion

Corre"t #ns$er: /$)$3

Rationa%e 1! +he problem$ or diagnostic label$ describes the client1s health problem or response#

Rationa%e 2! 'efining characteristics are the cluster of manifestations that indicate the presence of a particular

diagnostic statement#

Rationa%e ! A 2ualifier may or may not be presentE when a NAN'A label is followed by the word specify$ a2ualifier is re2uired#





Rationa%e !! +he etiology @related and ris- factors identifies the probable cause of the health problem#

Rationa%e ! +he nursing diagnosis is a statement about an alteration in the client1s health status#

&%o'a% Rationa%e:




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Question 2

Type: MCMA

As the 4&N54VN discusses the care plan with the other staff$ they note the following characteristics of a client1s

6at ris- for6 nursing diagnosis!


1. &roblem statement

2. 9actors contributing to the response

. +he words 6related to6

!. 'efining characteristics manifested by the client

. 'eviation from health

Corre"t #ns$er: /$)$

Rationa%e 1! A problem statement is part of the 6at ris- for6 nursing diagnosis#

Rationa%e 2! %tiology is part of the 6at ris- for6 nursing diagnosis#

Rationa%e ! +he words 6related to6 connect the problem and etiology in the 6at ris- for6 nursing diagnosticstatement#

Rationa%e !! 'efining characteristics are not yet present in the 6at ris- for6 nursing diagnosis#

Rationa%e ! 'eviation from health is not yet present in the 6at ris- for6nrsing diagnosis#

&%o'a% Rationa%e:







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Question

Type: MCSA

Dualifiers are added to some NAN'A statements to

1. %"plain the cause of the nursing diagnosis

2. ive additional meaning to the diagnostic statement

. Connect to the medical diagnosis

!. 0dentify collaborative problems

.

Corre"t #ns$er: )

Rationa%e 1! Dualifiers are added to give additional meaning to the diagnostic statement#


Rationa%e ! Dualifiers are added to give additional meaning to the diagnostic statement#

Rationa%e !! Dualifiers are added to give additional meaning to the diagnostic statement#

Rationa%e !

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 1Type: MCSA

0n the nursing diagnostic statement$ which of the following must be present for the diagnosis to be valid?

1. Minor characteristics

2. Actual nursing diagnosis





. Major defining characteristics

!. %tiology

.

Corre"t #ns$er:

Rationa%e 1! Minor characteristics may or may not be present#

Rationa%e 2! +his is a type of nursing diagnosis$ not a component#

Rationa%e ! Major and critical defining characteristics are the signs and symptoms that must be present for the

diagnosis to be present#

Rationa%e !! 0n a ris- nursing diagnosis$ there is no etiology$ and the diagnosis is still valid#

Rationa%e !

&%o'a% Rationa%e:



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Question 2

Type: MCSA

+he purpose of the nursing diagnosis is to

1. 'escribe disease and pathology

2. 'elegate nursing interventions

. 'esign nursing activities

!. 'irect the formation of client goals and e"pected outcomes

.

Corre"t #ns$er: 3

Rationa%e 1! +his is the purpose of a medical diagnosis#

Rationa%e 2! +he nursing diagnosis does not provide for delegation#





Rationa%e ! 'esigning nursing activities is done in the planning stage of the nursing process#

Rationa%e !! +he purpose of the nursing diagnosis is to direct the formation of client goals and outcomes$ and

possibly suggest interventions#

Rationa%e !

&%o'a% Rationa%e:



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Question

Type: MCMA

When evaluating the success of the nursing care plan$ the nurse remembers that evaluation is!


1. &lanned and ongoing

2. 'one collaboratively with the healthcare professional and the client

. &erformed to determine the client1s progress toward goal achievement

!. &erformed to determine the effectiveness of the nursing care plan

. &erformed verbally

Corre"t #ns$er: /$)$$3

Rationa%e 1! %valuation is a planned$ ongoing$ purposeful activity#

Rationa%e 2! ,oth the healthcare professional and the client evaluate progress toward client goal achievement#

Rationa%e ! %valuation is performed to determine client progress#

Rationa%e !! %valuation is performed to evaluate effectiveness of the nursing care plan$ and to determine the neeto change interventions#

Rationa%e ! +he nurse writes an evaluative statement after determining whether a goal has been met either on th

care plan or in the nurses notes#

&%o'a% Rationa%e:







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Question !

Type: MCMA

+he planning process includes which of the following characteristics!


1. 0s ongoing in nature

2. ,egins with first client contact

. 0nvolves anticipating and planning for clients1 needs after discharge

!. A formal plan of care

. Setting priorities


Rationa%e 1! 8ngoing planning is done by all nurses who wor- with the client#

Rationa%e 2! &lanning should be initiated as soon as possible after the initial assessment#

Rationa%e ! 'ischarge planning is a crucial part of comprehensive health care and begins at the first clientcontact#

Rationa%e !! &lanning may result in a formal or informal care plan#

Rationa%e ! &riority setting is the process of identifying nursing diagnoses and interventions in order from most

important to least important and is part of the planning stage#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question





Type: MCSA

When developing e"pected outcomes from nursing diagnoses$ the nurse will

1. &roduce at least one e"pected outcome

2. *se Maslow1s hierarchy of needs to prioriti:e the outcomes

. 'evelop long term goals

!. Write outcomes in terms of nursing activities

.

Corre"t #ns$er: /

Rationa%e 1! %ach nursing diagnosis should have at least one e"pected outcome that is measurable#


Rationa%e ! %ach nursing diagnosis should have at least one e"pected outcome that is measurable#

Rationa%e !! %ach nursing diagnosis should have at least one e"pected outcome that is measurable#

Rationa%e !

&%o'a% Rationa%e:



C%ient Need *u':


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Question 6

Type: MCMA

+he nurse follows which of the following guidelines for writing e"pected outcomes!


1. %nsure that the e"pected outcomes are compatible with therapies of other professionals

2. Combining goals with multiple nursing diagnoses saves time

. Avoid statements that start with permit or enable





!. *se observable$ measurable terms

. 'etermine goals based on nurses1 values and concerns about client health concerns

Corre"t #ns$er: /$$3

Rationa%e 1! +he nurse needs to determine that another professional has not prescribed therapies that are opposite

from the nursing outcomes#

Rationa%e 2! Ma-e sure that each goal is derived from only one nursing diagnosis#

Rationa%e ! Statements should start with 6the client will6 to focus on client behaviors#

Rationa%e !! Avoid vague words that could mean different things to different people#

Rationa%e ! oals need to be considered important by the client#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question /

Type: MCMA

Nursing interventions may be characteri:ed as!


1. 'irect care

2. 0ndependent

. 'ependent

!. Active

. &assive


Rationa%e 1! 'irect care is an intervention performed through interaction with the client#





Rationa%e 2! 0ndependent interventions are activities that nurses are licensed to do based on their -nowledge ands-ills#

Rationa%e ! 'ependent interventions are activities carried out under the physician1s orders or supervision#

Rationa%e !! Active interventions are not nursing interventions#

Rationa%e ! &assive interventions are not nursing interventions#

&%o'a% Rationa%e:



C%ient Need *u':


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Question 0

Type: MCSA

+he 4&N54VN selects nursing interventions to continue during which stage of the nursing process?

1. Assessment

2. 'iagnosis

. 0ntervention

!. %valuation

.

Corre"t #ns$er: 3

Rationa%e 1! Nursing interventions are not selected during assessmentE data collection occurs#

Rationa%e 2! Nursing interventions are not determined during diagnosis#

Rationa%e ! Nursing interventions are decided during this stage#

Rationa%e !! Nursing interventions are selected to continue during the evaluation phase#

Rationa%e !

&%o'a% Rationa%e:







C%ient Need *u':


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Question

Type: MCMA

+he nurse uses a variety of methods to collect data$ including!


1. Smelling

2. Bearing

. &lanned communication

!. 0ntuition

. &alpitation


Rationa%e 1! +he nurse uses observation$ which includes smelling$ seeing$ and hearing#


Rationa%e ! &lanned communication will ensure that the most information possible is obtained during theinterview#

Rationa%e !! 0ntuition is not a tool the nurse uses for data collection#

Rationa%e ! &alpitation is a fluttery feeling a client may e"perience in the chest$ or abdomen#

&%o'a% Rationa%e:



C%ient Need *u':Nursing+ntegrated Con"epts: Nursing &rocess! Assessment

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Question !

Type: MCSA

+he nurse identifies the elements of the goal statement$ e"plaining that the subject





1. Specifies action client is to perform

2. 0ncludes conditions that may be added

. 0ndicates the standard by which the client will perform

!. 0s the client

.

Corre"t #ns$er: 3

Rationa%e 1! +he action verb specifies action the client is to perform#

Rationa%e 2! +he measurable modifier includes conditions that may be added to the verb to e"plain how$ when$where or what#

Rationa%e ! +he criteria of desired performance indicates the standard by which the client will perform behavior

Rationa%e !! +he subject of the outcome or goal statement is the client or some attribute of the client#

Rationa%e !

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question !1

Type: S%D

0n the nursing process$ the steps of implementation are practiced as follows!

*tandard Te3t: Clic- and drag the options below to move them up or down#

Choi"e 1. 0mplementing nursing orders

Choi"e 2. 'ocumenting

Choi"e . (eassessing the client

Choi"e !. 'elegating

Choi"e . 'etermining the nurse1s need for assistance





Choi"e 6.

Corre"t #ns$er: $>$/$3$)

Rationa%e 1! +he nurse e"plains the procedure as the nursing order is carried out#

Rationa%e 2! Nursing actions are recorded$ as are client responses to interventions#

Rationa%e ! +he nurse reassess the client prior to action as new data may indicate new priorities#

Rationa%e !! +he 4&N54VN may delegate to unlicensed personnel if appropriate#

Rationa%e ! +he nurse may need assistance for safety$ stress reduction$ lac- of -nowledge or s-ills#

Rationa%e 6!

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question !2

Type: MCSA

1.

2.

.

!.

.

Corre"t #ns$er:

Rationa%e 1!

Rationa%e 2!

Rationa%e !

Rationa%e !!





Rationa%e !

&%o'a% Rationa%e:

Cogniti(e )e(e%:

C%ient Need:

C%ient Need *u':


)earning -ut"ome:

Question !

Type: MCSA

When providing client care and implementing the nursing plan the nurse utili:es which of the following s-ills in

all nursing activities?

1. Cognitive s-ills

2. 0nterpersonal s-ills

. +echnical s-ills

!. &sychomotor s-ills

.

Corre"t #ns$er: )

Rationa%e 1! Cognitive s-ills include problem solving and decision ma-ing# +hey are not always used in nursingactivities#

Rationa%e 2! 0nterpersonal s-ills are necessary for all nursing activities for conveying -nowledge$ attitudes$feelings$ interest$ and appreciation of the client1s cultural values and lifestyle#

Rationa%e ! Not all nursing activities re2uire hands7on s-ills#

Rationa%e !! &sychomotor s-ills re2uire communications with the client$ -nowledge$ and fre2uently manual

de"terity#

Rationa%e !

&%o'a% Rationa%e:



C%ient Need *u':






)earning -ut"ome:

Question !!

Type: MCSA

+he nurse evaluates the client!

1. 8n a continuous basis throughout the day

2. At the beginning of the shift

. After the initial intervention

!. When the initial intervention fails

.

Corre"t #ns$er: /

Rationa%e 1! +he nurse evaluates the client continuously throughout the day by determining if the objective from

the written care plan has been met#

Rationa%e 2! +he nurse evaluates the client continuously throughout the day by determining if the objective fromthe written care plan has been met#

Rationa%e ! +he nurse evaluates the client continuously throughout the day by determining if the objective from

the written care plan has been met#

Rationa%e !! +he nurse evaluates the client continuously throughout the day by determining if the objective fromthe written care plan has been met#

Rationa%e !

&%o'a% Rationa%e:



C%ient Need *u':


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Question !

Type: S%D

+he nurse understands that the nursing process step of implementation has several steps of its own# 4ist the steps

of implementation in the appropriate order$ from first to last#







Choi"e 2. (eassessing the client

Choi"e . 'elegating and supervising

Choi"e !. 'ocumenting nursing actions


Choi"e 6.

Corre"t #ns$er: )$>$/$$3

Rationa%e 1! %"plain procedures#

Rationa%e 2! New data may indicate new priorities#

Rationa%e ! 4&N54VN may delegate to unlicensed staff if appropriate#

Rationa%e !! (ecord interventions and client responses in nursing progress notes#

Rationa%e ! Assistance may be re2uired for safety$ stress reduction$ lac- of -nowledge or s-ills#

Rationa%e 6!

&%o'a% Rationa%e:



C%ient Need *u':


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Question !6

Type: MCMA

Characteristics of the nursing process include!


1. 0t is a logical method of providing individuali:ed nursing care#

2. Can only be utili:ed by (Ns#

. Components include assessing$ diagnosing$ planning$ interventions$ and evaluation#





!. &rovides a framewor- in which clients can discuss their actual and potential health problems#

. Components follow a logical se2uence$ one at a time#

Corre"t #ns$er: /$

Rationa%e 1! +he nursing process is a systematic$ logical method of providing individuali:ed nursing care#

Rationa%e 2! +he nursing process provides a common way of thin-ing for all nurses#

Rationa%e ! Components include assessment$ diagnosing @analysis$ planning$ implementing @intervention$ and

evaluating#

Rationa%e !! +he nursing process provides a framewor- in which nurses use their -nowledge and s-ills to e"preshuman caring$ and to help clients with their actual and potential health problems#

Rationa%e ! +he components of the nursing process follow a logical se2uence$ but more than one component can

be involved at any one time#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question !/

Type: MCSA+he role of the 4&N54VN in the assessment phase of the nursing process is to!

1. 0dentify client strengths and promote health maintenance#

2. Collect data and observe and report client status to the (N#

. 'evelop an individuali:ed care plan#

!. 8bserve or measure client responses to nursing interventions#

Corre"t #ns$er: )

Rationa%e 1! +he role of the 4&N54VN in assessing is to collect data$ observe client status$ and report abnormal

data or changes in client condition to the (N#

Rationa%e 2! +he role of the 4&N54VN in assessing is to collect data$ observe client status$ and report abnormal






Rationa%e ! +he role of the 4&N54VN in assessing is to collect data$ observe client status$ and report abnormaldata or changes in client condition to the (N#

Rationa%e !! +he role of the 4&N54VN in assessing is to collect data$ observe client status$ and report abnormal


&%o'a% Rationa%e:


C%ient Need: Bealth &romotion and Maintenance

C%ient Need *u':


)earning -ut"ome:

Question !0

Type: MCSA

+he 4&N54VN encourages the client to ambulate twice a day# +his is an e"ample of which stage of the nursing

process?

1. Assessment

2. &lanning

. 0mplementation

!. %valuation

Corre"t #ns$er:

Rationa%e 1! +his is not an e"ample of assessment#

Rationa%e 2! +he nursing care plan will direct actions#

Rationa%e ! +his is an e"ample of carrying out the plan of care#

Rationa%e !! +his is not an e"ample of evaluation#

&%o'a% Rationa%e:

Cogniti(e )e(e%: ApplyingC%ient Need: &hysiological 0ntegrity

C%ient Need *u':


)earning -ut"ome:

Question !

Type: MCSA





After administering pain medication to a postoperative client$ the 4&N54VN returns in . minutes to as- the clienif relief was obtained# +his is an e"ample of which stage of the nursing process?

1. &lanning

2. Assessing

. %valuation

!. 0mplementing

Corre"t #ns$er:

Rationa%e 1! +o observe or measure client response to nursing interventions is a component of the evaluation process#

Rationa%e 2! +o observe or measure client response to nursing interventions is a component of the evaluation

process#

Rationa%e ! +o observe or measure client response to nursing interventions is a component of the evaluation process#

Rationa%e !! +o observe or measure client response to nursing interventions is a component of the evaluation

process#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question

Type: MCSA

+he 4&N54VN contributes to nursing diagnoses by!

1. 0dentifying client strengths#

2. Naming health problems that can be prevented#

. *nderstanding the nursing diagnoses identified by the (N#

!. 'eveloping a list of independent nursing interventions#

Corre"t #ns$er:





Rationa%e 1! 0dentifying client strengths is an (N function#

Rationa%e 2! Naming health problems is an (N function#

Rationa%e ! *nderstanding the nursing diagnoses as they relate to the clients condition is the role of the

4&N54VN#

Rationa%e !! +he (N develops a list of collaborative and independent nursing interventions#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 1

Type: MCSA

Nursing assessment focuses on!

1. A client1s responses to a health problem#

2. +he nursing process#

. 'ocumentation#

!. +he client1s database#

Corre"t #ns$er: /

Rationa%e 1! All phases of the nursing process focus on a client1s response to a health problem#

Rationa%e 2! All phases of the nursing process depend on accurate and complete collection of data#

Rationa%e ! 'ocumentation of data is one of four activities in the assessment process#

Rationa%e !! +he client database includes information from many sources$ and is a result of many assessments#

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:





Question 2

Type: MCMA

+he 4&N54VN understands the four activities involved in assessment include!


1. athering information about a client#

2. 8rgani:ing data#

. 'ocumenting data#

!. Measuring responses to nursing interventions#

. Validating data#


Rationa%e 1! 'ata collection is a systematic process of gathering information about a client#

Rationa%e 2! 8rgani:ing data for easy retrieval can be done by following a nursing health history format#

Rationa%e ! 'ocumenting data in the client record is essential for ongoing evaluation of client condition#

Rationa%e !! Measuring response to nursing interventions is done in the evaluation stage of the nursing process#

Rationa%e ! Validating data @proving or supporting data is part of the assessment process#

&%o'a% Rationa%e:



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Question

Type: MCSA

+he nurse collects which -inds of data when assessing a client?

1. Subjective and primary

2. 8bjective and primary

. Subjective and objective

!. Subjective and secondary





Corre"t #ns$er:

Rationa%e 1! Subjective data @symptoms$ conditions that are apparent only to the person affected$ and objectivedata @signs$ those that can be measured or observed$ are collected by the nurse#

Rationa%e 2! Subjective data @symptoms$ conditions that are apparent only to the person affected$ and objective

data @signs$ those that can be measured or observed$ are collected by the nurse#

Rationa%e ! Subjective data @symptoms$ conditions that are apparent only to the person affected$ and objectivedata @signs$ those that can be measured or observed$ are collected by the nurse#

Rationa%e !! Subjective data @symptoms$ conditions that are apparent only to the person affected$ and objective

data @signs$ those that can be measured or observed$ are collected by the nurse#

&%o'a% Rationa%e:



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Question !

Type: MCSA

'uring data collection$ the nurse identifies which of the following as subjective data?

1. 4aughing during interview

2. 60 feel so di::y#6

. 6My dressing is bloody#6

!. +emperature is /..#)<9#

Corre"t #ns$er: )

Rationa%e 1! +he nurse can observe this data$ so it is objective data#

Rationa%e 2! +he nurse cannot observe this data$ so it is subjective data#

Rationa%e ! +he nurse can observe this data so it is objective data#

Rationa%e !! +he nurse can measure this data so it is objective data#

&%o'a% Rationa%e:







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Question

Type: MCMA

When reviewing the client nursing care plan$ the nurse notes which of the following components in each nursing

diagnosis?


1. 'iagnostic label

2. 'efining characteristics

. Dualifiers

!. %tiology

. Duestion

Corre"t #ns$er: /$)$3

Rationa%e 1! +he problem$ or diagnostic label$ describes the client1s health problem or response#

Rationa%e 2! 'efining characteristics are the cluster of manifestations that indicate the presence of a particular

diagnostic statement#

Rationa%e ! A 2ualifier might not be presentE when a NAN'A label is followed by the word specify$ a 2ualifier i

re2uired#

Rationa%e !! +he etiology @related and ris- factors identifies the probable cause of the health problem#

Rationa%e ! +he nursing diagnosis is a statement about an alteration in the client1s health status#

&%o'a% Rationa%e:

Cogniti(e )e(e%: ApplyingC%ient Need: Safe %ffective Care %nvironment

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Question 6

Type: MCMA





As the 4&N54VN discusses the care plan with the other staff$ they note the following characteristics of a client1s6at ris- for6 nursing diagnosis!


1. &roblem statement

2. 9actors contributing to the response

. +he words 6related to6

!. 'efining characteristics manifested by the client

. 'eviation from health


Rationa%e 1! A problem statement is part of the 6at ris- for6 nursing diagnosis#

Rationa%e 2! %tiology is part of the 6at ris- for6 nursing diagnosis#

Rationa%e ! +he words 6related to6 connect the problem and etiology in the 6at ris- for6 nursing diagnostic

statement#

Rationa%e !! 'efining characteristics are not yet present in the 6at ris- for6 nursing diagnosis#

Rationa%e ! 'eviation from health is not yet present in the 6at ris- for6 nursing diagnosis#

&%o'a% Rationa%e:



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Question /

Type: MCSA

Dualifiers are added to some NAN'A statements to!

1. %"plain the cause of the nursing diagnosis#

2. ive additional meaning to the diagnostic statement#

. Connect to the medical diagnosis#

!. 0dentify collaborative problems#





Corre"t #ns$er: )



Rationa%e ! Dualifiers are added to give additional meaning to the diagnostic statement#

Rationa%e !! Dualifiers are added to give additional meaning to the diagnostic statement#

&%o'a% Rationa%e:



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Question 0

Type: MCSA

0n the nursing diagnostic statement$ which of the following must be present for the diagnosis to be valid?

1. Minor characteristics

2. Actual nursing diagnosis

. Major defining characteristics

!. %tiology

Corre"t #ns$er:

Rationa%e 1! Minor characteristics might not be present#

Rationa%e 2! +his is a type of nursing diagnosis$ not a component#

Rationa%e ! Major and critical defining characteristics are the signs and symptoms that must be present for the

diagnosis to be present#

Rationa%e !! 0n a ris- nursing diagnosis$ there is no etiology$ and the diagnosis is still valid#

&%o'a% Rationa%e:



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Question

Type: MCSA

+he purpose of the nursing diagnosis is to!

1. 'escribe disease and pathology#

2. 'elegate nursing interventions#

. 'esign nursing activities#

!. 'irect the formation of client goals and e"pected outcomes#

Corre"t #ns$er: 3

Rationa%e 1! +his is the purpose of a medical diagnosis#

Rationa%e 2! +he nursing diagnosis does not provide for delegation#

Rationa%e ! 'esigning nursing activities is done in the planning stage of the nursing process#

Rationa%e !! +he purpose of the nursing diagnosis is to direct the formation of client goals and outcomes$ and possibly suggest interventions#

&%o'a% Rationa%e:




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Question 6

Type: MCMA

When evaluating the success of the nursing care plan$ the nurse remembers that evaluation is!


1. &lanned and ongoing#

2. 'one collaboratively with the healthcare professional and the client#

. &erformed to determine the client1s progress toward goal achievement#

!. &erformed to determine the effectiveness of the nursing care plan#





. &erformed verbally#

Corre"t #ns$er: /$)$$3

Rationa%e 1! %valuation is a planned$ ongoing$ purposeful activity#

Rationa%e 2! ,oth the healthcare professional and the client evaluate progress toward client goal achievement#

Rationa%e ! %valuation is performed to determine client progress#

Rationa%e !! %valuation is performed to evaluate effectiveness of the nursing care plan$ and to determine the nee

to change interventions#

Rationa%e ! +he nurse writes an evaluative statement either on the care plan or in the nurses notes afterdetermining whether a goal has been met#

&%o'a% Rationa%e:



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Question 61

Type: MCMA

+he planning process includes which of the following characteristics?


1. 0s ongoing in nature#

2. ,egins with first client contact#

. 0nvolves anticipating and planning for clients1 needs after discharge#

!. A formal plan of care

. Setting priorities


Rationa%e 1! 8ngoing planning is done by all nurses who wor- with the client#

Rationa%e 2! &lanning should be initiated as soon as possible after the initial assessment#





Rationa%e ! 'ischarge planning is a crucial part of comprehensive health care$ and begins at the first clientcontact#

Rationa%e !! &lanning can result in a formal or informal care plan#

Rationa%e ! &riority setting is the process of identifying nursing diagnoses and interventions in order from most

important to least important$ and is part of the planning stage#

&%o'a% Rationa%e:



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Question 62

Type: MCSAWhen developing e"pected outcomes from nursing diagnoses$ the nurse will!

1. &roduce at least one e"pected outcome#

2. *se Maslow1s hierarchy of needs to prioriti:e the outcomes#

. 'evelop long7term goals#

!. Write outcomes in terms of nursing activities#

Corre"t #ns$er: /



Rationa%e ! %ach nursing diagnosis should have at least one e"pected outcome that is measurable#

Rationa%e !! %ach nursing diagnosis should have at least one e"pected outcome that is measurable#

&%o'a% Rationa%e:



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Question 6





Type: MCMA

+he nurse follows which of the following guidelines for writing e"pected outcomes?


1. %nsure that the e"pected outcomes are compatible with therapies of other professionals#

2. Combining goals with multiple nursing diagnoses saves time#

. Avoid statements that start with permit or enable#

!. *se observable$ measurable terms#

. 'etermine goals based on nurses1 values and client health concerns#

Corre"t #ns$er: /$$3

Rationa%e 1! +he nurse needs to determine that another professional has not prescribed therapies that are opposite

from the nursing outcomes#

Rationa%e 2! Ma-e sure that each goal is derived from only one nursing diagnosis#

Rationa%e ! Statements should start with 6+he client will6 to focus on client behaviors#

Rationa%e !! Avoid vague words that could mean different things to different people#

Rationa%e ! oals need to be considered important by the client#

&%o'a% Rationa%e:



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Question 6!

Type: MCMA

Nursing interventions may be characteri:ed as!


1. 'irect care#

2. 0ndependent#





. 'ependent#

!. Active#

. &assive#


Rationa%e 1! 'irect care is an intervention performed through interaction with the client#

Rationa%e 2! 0ndependent interventions are activities that nurses are licensed to do based on their -nowledge and

s-ills#

Rationa%e ! 'ependent interventions are activities carried out under the physician1s orders or supervision#

Rationa%e !! Active interventions are not nursing interventions#

Rationa%e ! &assive interventions are not nursing interventions#

&%o'a% Rationa%e:



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Question 6

Type: MCSA+he 4&N54VN selects nursing interventions to continue during which stage of the nursing process?

1. Assessment

2. 'iagnosis

. 0ntervention

!. %valuation

Corre"t #ns$er: 3

Rationa%e 1! Nursing interventions are not selected during assessmentE data collection occurs#

Rationa%e 2! Nursing interventions are not determined during diagnosis#

Rationa%e ! Nursing interventions are decided during this stage#





Rationa%e !! Nursing interventions continue during the evaluation phase#

&%o'a% Rationa%e:



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Question 66

Type: MCMA

+he nurse uses a variety of methods to collect data$ including!


1. Smelling#

2. Bearing#

. &lanned communication#

!. 0ntuition#

. &alpitation#




Rationa%e ! &lanned communication will ensure that the most information possible is obtained during theinterview#

Rationa%e !! 0ntuition is not a tool the nurse uses for data collection#

Rationa%e ! &alpitation is a fluttery feeling a client might e"perience in the chest$ or abdomen#

&%o'a% Rationa%e:



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Question 6/

Type: MCSA

+he nurse identifies the elements of the goal statement$ e"plaining that the subject!

1. Specifies the action the client is to perform#

2. 0ncludes conditions that may be added#

. 0ndicates the standard by which the client will perform#

!. 0s the client#

Corre"t #ns$er: 3

Rationa%e 1! +he action verb specifies action the client is to perform#

Rationa%e 2! +he measurable modifier includes conditions that may be added to the verb to e"plain how$ when$

where$ or what#

Rationa%e ! +he criteria of desired performance indicates the standard by which the client will perform behavior

Rationa%e !! +he subject of the outcome or goal statement is the client or some attribute of the client#

&%o'a% Rationa%e:



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Question 60

Type: S%D

0n the nursing process$ the steps of implementation are practiced as follows!



Choi"e 2. 'ocumenting

Choi"e . (eassessing the client

Choi"e !. 'elegating






Corre"t #ns$er: $>$/$=$)

Rationa%e 1! +he nurse e"plains the procedure as the nursing order is carried out#

Rationa%e 2! Nursing actions are recorded$ as are client responses to interventions#

Rationa%e ! +he nurse reassesses the client prior to action$ as new data could indicate new priorities#

Rationa%e !! +he 4&N54VN may delegate to unlicensed personnel if appropriate#

Rationa%e ! +he nurse might need assistance for safety$ stress reduction$ or lac- of -nowledge or s-ills#

&%o'a% Rationa%e:



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Question 6

Type: MCSA

When providing client care and implementing the nursing plan$ the nurse utili:es which of the following s-ills in

all nursing activities?

1. Cognitive s-ills

2. 0nterpersonal s-ills

. +echnical s-ills

!. &sychomotor s-ills

Corre"t #ns$er: )

Rationa%e 1! Cognitive s-ills include problem solving and decision ma-ing# +hey are not always used in nursing

activities#

Rationa%e 2! 0nterpersonal s-ills are necessary for all nursing activities for conveying -nowledge$ attitudes$

feelings$ interest$ and appreciation of the client1s cultural values and lifestyle#

Rationa%e ! Not all nursing activities re2uire hands7on s-ills#

Rationa%e !! &sychomotor s-ills re2uire communications with the client$ -nowledge$ and$ fre2uently$ manual

de"terity#

&%o'a% Rationa%e:







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Question /

Type: MCSA

+he nurse evaluates the client!

1. 8n a continuous basis throughout the day#

2. At the beginning of the shift#

. After the initial intervention#

!. When the initial intervention fails#

Corre"t #ns$er: /

Rationa%e 1! +he nurse evaluates the client continuously throughout the day by determining whether the objective

from the written care plan has been met#

Rationa%e 2! +he nurse evaluates the client continuously throughout the day by determining whether the objectivefrom the written care plan has been met#

Rationa%e ! +he nurse evaluates the client continuously throughout the day by determining whether the objective


Rationa%e !! +he nurse evaluates the client continuously throughout the day by determining whether the objective


&%o'a% Rationa%e:



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Question /1

Type: S%D

+he nurse understands that the nursing process step of implementation has several steps of its own# 4ist the stepsof implementation in the appropriate order$ from first to last#







Choi"e 2. (eassessing the client

Choi"e . 'elegating and supervising

Choi"e !. 'ocumenting nursing actions


Corre"t #ns$er: $/$3$>$)

Rationa%e 1! %"plain procedures#

Rationa%e 2! New data could indicate new priorities#

Rationa%e ! +he 4&N54VN may delegate to unlicensed staff if appropriate#

Rationa%e !! (ecord interventions and client responses in nursing progress notes#

Rationa%e ! Assistance might be re2uired for safety$ stress reduction$ or lac- of -nowledge or s-ills#

&%o'a% Rationa%e:



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