NUR3632 Foundations Exam 3 Study Questions With
Complete Solutions
10. A nurse is diagnosing an 11-year-old 6th grade student
following a physical assessment. The nurse notes that the
student's grades have dropped, she has difficulty completing her
work on time, and she frequently rubs her eyes and squints. Her
visual acuity on a Snellen's eye chart is 160/20. Which nursing
diagnosis would be most appropriate?
Deficient Knowledge related to visual impairment
Ineffective Role Performance (Student) related to visual
impairment
Disturbed Body Image related to visual impairment
Delayed Growth and Development related to visual impairment
Correct Answers 10. b. An important role for an 11-year-old is
that of student. Her impaired vision is clearly disturbing her role
performance as a student, as evidenced by her lower grades.
Although the other options may also represent accurate
diagnoses for this patient, they do not flow from the data
presented.
10. A nurse is preparing a family for a terminal weaning of a
loved one. Which nursing actions would facilitate this process?
Select all that apply.
Participate in the decision-making process by offering the family
information about the advantages and disadvantages of
continued ventilatory support.
Explain to the family what will happen at each phase of the
weaning and offer support.
Check the orders for sedation and analgesia, making sure that
the anticipated death is comfortable and dignified.
,Tell the family that death will occur almost immediately after
the patient is removed from the ventilator.
Tell the family that the decision for terminal weaning of a
patient must be made by the primary care provider.
Set up mandatory counseling sessions for the patient and family
to assist them in making this end-of-life decision. Correct
Answers 10. a, b, c. A nurse's role in terminal weaning is to
participate in the decision-making process by offering helpful
information about the benefits and burdens of continued
ventilation and a description of what to expect if terminal
weaning is initiated. Supporting the patient's family and
managing sedation and analgesia are critical nursing
responsibilities. In some cases, competent patients decide that
they wish their ventilatory support ended; more often, the
surrogate decision makers for an incompetent patient determine
that continued ventilatory support is futile. Because there are no
guarantees how any patient will respond once removed from a
ventilator, and because it is possible for the patient to breathe on
one's own and live for hours, days, and, rarely, even weeks, the
family should not be told that death will occur immediately.
Counseling sessions may be arranged if requested but are not
mandatory to make this decision
10. A nurse is teaching a patient with a sleep disorder how to
keep a sleep diary. Which data would the nurse have the patient
document? Select all that apply.
Daily mental activities
Daily physical activities
Morning and evening body temperature
Daily measurement of fluid intake and output
Presence of anxiety or worries affecting sleep
,Morning and evening blood pressure readings Correct Answers
10. a, b, e. A sleep diary includes mental and physical activities
performed during the day and the presence of any anxiety or
worries the patient may be experiencing that affect sleep. A
record of fluid intake and output, body temperature, and blood
pressure is not usually kept in a sleep diary.
10. A nurse who is caring for a morbidly obese male teenager
forms a contractual agreement with him to achieve his weight
goals. Which statement best describes the nature of this
agreement?
"This agreement forms a legal bond between the two of us to
achieve your weight goals."
"This agreement will motivate the two of us to do what is
necessary to meet your weight goals."
"This agreement will help us determine what learning outcomes
are necessary to achieve your weight goals."
"This agreement will limit the scope of the teaching session and
make stated weight goals more attainable." Correct Answers
10. b. A contractual agreement is a pact two people make setting
out mutually agreed-on goals. Contracts are usually informal
and not legally binding. When teaching a patient, such an
agreement can help motivate both the patient and the teacher to
do what is necessary to meet the patient's learning outcomes.
The agreement notes the responsibilities of both the teacher and
the learner, emphasizing the importance of the mutual
commitment.
10. A nurse who is comfortable with one's own spirituality is
caring for patients who need spiritual counseling. Which nursing
action would be most appropriate for these patients?
, Calling the patient's own spiritual adviser first
Asking whether the patient has a spiritual adviser the patient
wishes to consult
Attempting to counsel the patient and, if unsuccessful, making a
referral to a spiritual adviser
Advising the patient and spiritual adviser concerning health
options and the best choices for the patient Correct Answers
10. b. Even when a nurse feels comfortable discussing spiritual
concerns, the nurse should always check first with patients to
determine whether they have a spiritual adviser to consult.
Calling the patient's own spiritual adviser (answer a) may be
premature if it is a matter the nurse can handle. Answers c and d
deny patients the right to speak privately with their spiritual
adviser from the outset, if this is what they prefer.
10. A nursing student asks the charge nurse about legal liability
when performing clinical practice. Which statement regarding
liability is true?
Students are not responsible for their acts of negligence resulting
in patient injury.
Student nurses are held to the same standard of care that would
be used to evaluate the actions of a registered nurse.
Hospitals are exempt from liability for student negligence if the
student nurse is properly supervised by an instructor.
Most nursing programs carry group professional liability making
student personal professional liability insurance Correct
Answers 10. b. Student nurses are held to the same standard of
care that would be used to evaluate the actions of a registered
nurse. Student nurses are responsible for their own acts of
negligence if these result in patient injury. A hospital may also
be held liable for the negligence of a student nurse enrolled in a
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