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Nurs104 Final Exam
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Nurs104 Final Exam 2023- 2024 A nurse will arrive at a nursing diagnosis through the nursin g process step of: - ANSWER assessment. A student nurse can begin to develop critical thinking skills by m eans of: - ANSWER listening attentively and focusing on the speaker's words and meaning. An emergency room nurse will give first priority to the patient wi th the most critical need, which is the patient who: - ANSWER complains of severe chest pai n. Constant nursing assessments and evaluations of the patient will m ost likely result in: - ANSWER the nursing care plan changing to reflect appropria te priorities. Descriptions of the activities involved in the nursing diagnosis step of the nursing process are: (Select all that apply.) - ANSWER determination of potential he alth problems., clustering of related assessments. In the collaborative process of delivering care based on the nursi ng process, the responsibility of the LPN/LVN is to: - ANSWER collect data of health status. Once the nursing plan has been initiated, the nursing care pl an will: - ANSWER change as the patient's condition changes. The activity that is implementation in nursing care is: - ANSWER changing the patient's surgical dressing. The effect of using a scientific problem-solving approach in n ursing care will cause decision making to be: - ANSWER improved nursing care outcomes. The nurse who uses the nursing process will: - ANSWER approach th e patient's disorder in a step- by-step method. The order in which the nursing process is approached is: - A NSWER assessment, nursing diagnosis, planning, implementation, evaluation. The participants of the planning stage of the nursing proce ss during which the health goals are defined include the: - ANSWER health team, the patient, and the patient's family. When a nurse prioritizes the patient care, consideration is given to: - ANSWER considering situations that may result in an alteration of health. When a patient states, "I can't walk very well," the first proble m-solving step would be to: - ANSWER find out what the problem is, such as weakness or poor ba lance. When a resident in the nursing home complains of constipat ion, the nurse performs a digital rectal examination and finds a hard fecal mass. This is an examp le of: - ANSWER assessment. When the nurse checks to see whether a patient has had relie f 45 minutes after administering pain medication, the nurse is performing a(n): - ANSWER evaluation. A nursing care plan consists of: - ANSWER nursing orders for in dividualized interventions to assist the patient to meet expected outcomes. A nursing diagnosis consists of: - ANSWER diagnostic labels formu lated by the North American Nursing Diagnosis Association-International (NANDA-I). A patient with visual impairment is identified as at risk f or falls related to blindness. An appropriate intervention would be to: - ANSWER arrange furni shings in room to provide clear pathways and orient the patient to these. An elderly patient with a medical diagnosis of chronic lung disease has developed pneumonia. She is coughing frequently and expectorating thick, sticky secretions . She is very short of breath, even with oxygen running, and she is exhausted and says she "can't breathe." Based on this information, an appropriately worded nursing diagnosi s for this patient is - ANSWER Airway clearance, ineffective, related to lung secretions as evidenced by cough and shortness of breath. During the assessment phase of the nursing process, the nurse - ANSWER g athers, organizes, and documents data in a logical database. The statements that are correctly stated as expected outcomes are: (Sel ect all that apply.) - ANSWER Patient will be able to ambulate using a walker inde pendently within 3 days., Patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours. A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen satura tion level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is: - ANSWER Airway clearance, ineffective, related to retained secreti ons as evidenced by expectoration of thick green mucus, oxygen saturation level of 90% , and audible crackles in the base of the right lung. A nursing care plan consists of: - ANSWER nursing orders for in dividualized interventions to assist the patient to meet expected outcomes. A nursing diagnosis consists of: - ANSWER diagnostic labels formu lated by the North American Nursing Diagnosis Association-International (NANDA-I). A patient has a nursing diagnosis of Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by in creasing confusion and weight loss of more than 30-pounds over the last 6 months. An a ppropriate short-term goal for this patient is to: - ANSWER eat 50% of six small meals each day by the end of 1 week. A patient with visual impairment is identified as at risk f or falls related to blindness. An appropriate intervention would be to: - ANSWER arrange furni shings in room to provide clear pathways and orient the patient to these. After the admission assessment is completed, on subsequent shifts or days, the nurse: - ANSWER assesses the patient briefly in the first hour of the shift. Aside from the information obtained from the patient (primary sou rce) in the admission interview, the nurse will also access: (Select all that apply - ANSWE R the patient's family., the admission note., the physician's history and physical., an observati on of the patient for non-verbal clues. If a patient has several nursing diagnoses, the nurse will fi rst: - ANSWER prioritize th e nursing problems according to Maslow's hierarchy of needs. In an acute care facility, a nursing care plan is usually reviewe d and updated - ANSWER every 24 hours. The major goal of the admission interview (usually performed by the RN) is to: - ANSWER identify the patient's major complaints. The nurse clarifies that nursing orders are also called: - ANSWER interventions. The nurse designs the goals for patients in long-term facilities to be: - ANSWER long-term. The nurse performing an admission interview on an elderly p erson should: - ANSWER allow more time for a response to questions. The nurse should make a point when closing the initial interview to: (Select all that apply.) - ANSWER summarize the problems discussed., thank the patient for his or her time. The nursing diagnoses that has the highest priority is: - ANSWER Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating.The benefits of buying summaries with Stuvia:
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