Exam (elaborations)
GNUR 238 Exam #2 Latest Update
- Course
- Institution
GNUR 238 Exam #2 Latest Update ...
[Show more]
Content preview
GNUR 238 Exam #2 Latest UpdateAnswer: C --> The nursing process is the methodology used to "think like a nurse."
Providing patient-centered care (a) and enhancing communication among health team
members (d) is facilitated through the use of care plans.
Collaborating with rather than identifying members of the health care team (b) is part of
many plans of care. - Answer What is the purpose of the nursing process?
a. Providing patient-centered care
b. Identifying members of the health care team
c. Organizing the ways nurses think about patient care
d. Facilitating communication among members of the health care team
Answer: D
In an emergent situation, the nurse initially focuses on the patient's chief complaint to
determine its cause. Before initiating care, the nurse gathers information on the other
topics. - Answer A patient comes to the emergency department complaining of nausea
and vomiting. What should the nurse ask the patient about first?
a. Family history of diabetes
b. Medications the patient is taking
c. Operations the patient has had in the past
d. Severity and duration of the nausea and vomiting
Answer: D
The nurse collects primary data directly from patients who are alert and oriented.
Family members and other members of the health care team may provide secondary
data on patients. - Answer An alert and oriented patient is admitted to the hospital with
chest pain. Who is the best source of primary data on this patient?
a. Family member
b. Physician
c. Another nurse
d. Patient
Answer: B
,Each nursing diagnosis label identifies either a patient problem or need, which is its
purpose.
Resolving patient confusion, meeting accreditation requirements, and articulating the
nurse's scope of practice are not related to the purpose of the nursing diagnostic
process. - Answer What is the primary purpose of the nursing diagnosis?
a. Resolving patient confusion
b. Communicating patient needs
c. Meeting accreditation requirements
d. Articulating the nursing scope of practice
Answer: C
Nursing diagnoses emerge from groupings of clustered data collected during the
assessment phase of the nursing process.
Choices A, B, and D are all part of the clustered data used to make a nursing diagnosis. -
Answer On what premise is a nursing diagnosis identified for a patient?
a. First impressions
b. Nursing intuition
c. Clustered data
d. Medical diagnoses
Answer: A
Goals are to be patient-focused, realistic, and measurable. Only the first goal meets
these three criteria. - Answer Which statement is an appropriately written short-term
goal?
a. Patient will walk to the bathroom independently without falling within 2 days after
surgery.
b. Nurse will watch patient demonstrate proper insulin injection technique each
morning.
c. Patient's spouse will express satisfaction with patient's progress before discharge.
d. Patient's incision will be well approximated each time it is assessed by the nurse.
Answer: A --> Patient needs are always the primary focus of nursing interventions.
Nursing concerns, physician priorities, and family requests can provide additional
guidance in the development of a patient-centered plan of care. - Answer What should
,be the primary focus for nursing interventions?
a. Patient needs
b. Nurse concerns
c. Physician priorities
d. Patient's family requests
Answer: C --> Knowing the scope of practice of the other team member is critical to
understanding what is appropriate and safe to delegate to that person.
It is unnecessary to locate or meet with all members of the health care team prior to
delegation. Physicians are already aware of potential complications related to patient
care. - Answer Which nursing action is critical before delegating interventions to
another member of the health care team?
a. Locate all members of the health care team.
b. Notify the physician of potential complications.
c. Know the scope of practice for the other team member.
d. Call a meeting of the health care team to determine the needs of the patient.
Answer: A
When a patient shares a concern, the first action by the nurse is to assess potential
reasons for the patient's problem. Depending on the underlying reason for the patient's
inability to sleep, the nurse may then want to administer prescribed sleep medication,
teach the patient some relaxation techniques, or discuss patient behaviors with the
primary care provider. - Answer A patient reports feeling tired and complains of not
sleeping at night. What action should the nurse perform first?
a. Identify reasons the patient is unable to sleep.
b. Request medication to help the patient sleep.
c. Tell the patient that sleep will come with relaxation.
d. Notify the physician that the patient is restless and anxious.
Answer: C --> The nurse should evaluate the need to continue or discontinue a plan of
care if a patient has met a short-term goal.
Wrong answers:
A) It is unnecessary to consult the surgeon unless there is a concern.
B) Discontinuing the care plan may be premature, and the decision needs to be
, evaluated before taking action. The patient's intake and output will continue to be
monitored throughout hospitalization, not just for 1 hour after surgery.
D) Other interventions may still require implementation and other goals may not yet
have been met - Answer What action should the nurse take regarding a patient's plan of
care if the patient appears to have met the short-term goal of urinating within 1 hour
after surgery?
a. Consult the surgeon to see if the clinical pathway is being followed.
b. Discontinue the plan of care, because the patient has met the established goal.
c. Monitor patient urine output to evaluate the need for the current plan of care.
d. Notify the patient that the goal has been attained and no further intervention is
needed.
Critical Thinking - Answer Involves the application of knowledge and experience to
identify patient problems and to direct clinical judgments and actions that result in
positive patient outcomes. It is influenced by scientific research and best practice. In
nursing, ___________ is used synonymously with problem solving, decision making,
reasoning, and judgment.
Critical Reasoning - Answer Uses critical thinking, knowledge, and experience to
develop solutions to problems and make decisions in a clinical setting. These skills
develop over time and increase with knowledge and experience.
Reflection - Answer Deliberate thinking about something that has occurred or
happened. Done during practice to improve future caregiving.
Evidence - Answer Identification of science and research that ensures nursing practice
is within standards of care
Standards - Answer Established by the American Nurse's Association (ANA) based in
areas like ethics, research, leadership, and collaboration. Determining what is the most
current evidence based practice.
1. Their role
2. Their scope of practice
3. The competency of the person - Answer What must a nurse know about the recipient
of a delegated task?
Routine and aimless thinking
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Flat. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $9.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
79373 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now