Download PDF test bank for essentials for nursing practice 8th edition by potter and perry

Test Bank for Essentials for Nursing Practice 8th Edition by Potter and Perry Chapter 09: Nursing Process Potter: Essentials for Nursing Practice, 8th Edition MULTIPLE CHOICE A nurse is collecting data on a patient who is being admitted into hospice care The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained The nurse is currently involved in which step of the nursing process? a Assessment b Implementation c Evaluation d Diagnosing ANS: A Assessment is the deliberate and systematic collection of data about a patient The data will reveal a patient’s current and past health status, functional status, and present and past coping patterns A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat Implementation is the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care Evaluation is crucial to deciding whether, after interventions have been delivered, a patient’s condition or well-being improves PTS: DIF: Cognitive Level: Applying (Application) REF: 124 OBJ: Describe each step of the nursing process TOP: Nursing Process: Assessment Care MSC: NCLEX: Management of The nurse is admitting a patient to the unit and asks the patient about the health history The nurse is engaged in which component of the nursing process? a Evaluation b Diagnosis c Assessment d Planning ANS: C The nurse is in the assessment phase An assessment database includes a patient’s comprehensive health history, which includes information about a patient’s physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system The database also includes physical examination findings and a summary of results from laboratory and diagnostic testing A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat Evaluation is crucial to deciding whether, after interventions have been delivered, a patient’s condition or well-being improves Planning involves setting priorities, identifying patientcentered goals and expected outcomes, and prescribing nursing interventions PTS: DIF: Cognitive Level: Applying (Application) REF: 124 OBJ: Discuss approaches to data collection in nursing assessment TOP: Nursing Process: Assessment Care MSC: NCLEX: Management of A postoperative patient is continuing to have incisional pain As part of the nurse’s assessment, the nurse notes that the patient is grimacing when he or she changes position The patient’s grimace can be useful in the assessment and can be described as which of the following? a Cue b Inference c Diagnosis d Health pattern ANS: A Grimacing is a cue A cue is information that a nurse obtains through use of the senses An inference is your judgment or interpretation of these cues Gordon’s functional health patterns are a type of database format to obtain a comprehensive assessment A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat PTS: DIF: Cognitive Level: Applying (Application) REF: 125 data analysis OBJ: Explain the type of conclusions that result from TOP: Nursing Process: Assessment Care MSC: NCLEX: Management of A postoperative patient has denied the need for pain medication The nurse has noted that the patient describes the pain as a “1” on a to 10 scale The nurse also notes that the patient grimaces when he or she changes position and guards the incision The nurse believes that the patient is experiencing pain based on the information gathered in the assessment What is this phenomenon known as? a Cue b Inference c Diagnosis d Health pattern ANS: B The nurse made a judgment, which is an inference, that the patient is experiencing pain An inference is a nurse’s judgment or interpretation of a cue A cue is information that you obtain through use of the senses Gordon’s functional health patterns are a type of database format to obtain a comprehensive assessment A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat such as impaired tissue perfusion PTS: DIF: Cognitive Level: Applying (Application) REF: 125 data analysis OBJ: Explain the type of conclusions that result from TOP: Nursing Process: Assessment Care MSC: NCLEX: Management of A nurse is collecting data during the assessment of a patient During the assessment, the nurse collects both subjective and objective data Which information should the nurse consider as subjective data? a Heart rate of 96 b Incisional erythema c Emesis of 150 mL d Sharp, burning pain ANS: D Sharp, burning pain is subjective Subjective data are patients’ verbal descriptions of their health problems Only patients provide subjective data Heart rate, incisions, and emesis are all objective data Objective data are observations or measurements of a patient’s health status PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 126 data OBJ: Differentiate between subjective and objective TOP: Nursing Process: Assessment Care MSC: NCLEX: Management of The nurse has just completed an assessment on a patient with a fractured right femur Which data will the nurse categorize as objective? a The patient’s toes of right foot are warm and pink b The patient reports a dull ache in the right hip c The patient says feels tired all the time d The patient is concerned about insurance coverage ANS: A Toes pink and warm are objective data Objective data are observations or measurements of a patient’s health status Subjective data are patients’ verbal descriptions of their health problems Only patients provide subjective data PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 126 data OBJ: Differentiate between subjective and objective TOP: Nursing Process: Assessment Care MSC: NCLEX: Management of A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a nurse As the student nurse charts the interaction, which statement is the best way to document what happened? a Appears to be in pain as evidenced by grouchy behavior b Behavior is inappropriate, requests registered nurse the assessment c States, “I want a registered nurse to my assessment” d Is grumpy, registered nurse notified ANS: C When a nurse collects objective data, he or she should apply critical thinking intellectual standards (e.g., clear, precise, and consistent) Nurses not include personal interpretive statements The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care If you not report or record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient Grouchy, inappropriate, and grumpy are personal interpretive statements and should be avoided PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 126 | 131 OBJ: Explain the relationship between critical thinking and steps of the nursing process TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care A mother of five children is admitted to the hospital for abdominal pain The nurse asks a series of questions before performing a physical assessment The patient answers the questions When asking the patient some other questions, the patient’s spouse starts to answer As the admission process progresses and the nurse gathers subjective data, the nurse requests that the patient answer the next questions What is the rationale for the nurse’s behavior? a The patient is exhibiting confusion b The spouse is being obnoxious c The patient is the best source of information d The spouse is too controlling ANS: C A patient is usually the best source of information A patient who is alert and answers questions appropriately provides the most accurate information about health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living There is no evidence in the scenario to indicate confusion on the patient’s part or that the spouse was obnoxious or too controlling The nurse needs more data before saying the spouse is obnoxious or controlling PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 127 OBJ: Discuss approaches to data collection in nursing assessment TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care A 2-year-old patient is being admitted to the outpatient surgery for a tonsillectomy Which will provide the best primary source of information for what comforts the patient when stressed? a Patient chart b Patient c Parents d Surgeon ANS: C Family members and significant others are primary sources of information for infants, children, critically ill adults, patients with mental handicaps, or patients who are unconscious or have reduced cognitive function The patient is too young The patient’s chart is a source but not a primary source The parents are a better source than the surgeon PTS: DIF: Cognitive Level: Analyzing (Analysis) b It requires monitoring for signs of acid-base imbalance c It requires evaluating the effects of positioning on oxygenation d It requires both nursing and physician-prescribed interventions ANS: D A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status When collaborative problems develop, nurses collaborate with personnel from other health care disciplines, such as social workers and dietitians and physicians Adequate hydration, acid-base imbalance, and oxygenation not make a collaborative problem PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 131 data analysis OBJ: Explain the type of conclusions that result from TOP: Nursing Process: Evaluation Adaptation MSC: NCLEX: Physiological 21 A patient states, “I’m burning up, and I have a fever.” The nurse takes the patient’s temperature, observes the skin for flushing, and feels the skin temperature This is an example of subjective data a validating b clustering c reviewing d documenting ANS: A Validation of assessment data is the comparison of data with another source to confirm accuracy The nurse reviews data to validate that measurable, objective physical findings support subjective data A data cluster is a set of signs or symptoms that are grouped in a logical order When a nurse reviews a patient’s subjective data, the nurse is examining the patient’s own interpretation of his or her condition Documenting information includes the written details of the assessment PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 130 | 137 OBJ: Discuss approaches to data collection in nursing assessment TOP: Nursing Process: Assessment Care 22 MSC: NCLEX: Management of Upon assessment, the nurse finds that a patient has a heart rate of 66 beats per minute, a respiratory rate of 12 breaths per minute, and a blood pressure of 120/80 mm Hg The nurse obtained which type of data? a Personal b Demographic c Subjective d Objective ANS: D Objective data are observations or measurements of a patient’s health status Personal and demographic data refer to patient’s name, age, sex, and so on Subjective data are patients’ verbal descriptions about their health problems Demographic data includes birth, gender, address, family members’ names and addresses PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 126 data OBJ: Differentiate between subjective and objective TOP: Nursing Process: Assessment Care 23 MSC: NCLEX: Management of A patient has lost 10 pounds in the last months from breast cancer and chemotherapy The chemotherapy has caused the patient to not eat Which nursing diagnosis should the nurse use to develop the plan of care? a Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Food Intake b Imbalanced Nutrition: Less Than Body Requirements Related to Cancer c Imbalanced Nutrition: Less Than Body Requirements Related to Loss of Weight d Imbalanced Nutrition: Less Than Body Requirement Related to Insufficient Prescription of Chemotherapy ANS: A Imbalanced Nutrition: Less Than Body Requirement is the diagnostic label, whereas decreased food intake is the state of related factor(s) or etiology The identification of a nursing diagnosis flows from the assessment and diagnostic process Nursing diagnoses are worded in a two-part format: the diagnostic label followed by a statement of a related factor Identify the patient’s response, not the medical diagnosis Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis Breast cancer is a medical diagnosis Identify the problem and etiology to avoid a circular statement Such statements are vague and give no direction to nursing care Less than body requirements and loss of weight is circular Avoid legally inadvisable statements that imply blame, negligence, or malpractice The diagnosis that states insufficient prescription of chemotherapy implies that the health care provider gave an inadequate prescription PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 135-136 | 137-139 OBJ: Describe the way in which defining characteristics and the etiological process individualize a nursing diagnosis Process: Assessment TOP: Nursing MSC: NCLEX: Management of Care 24 A nurse develops a nursing diagnosis for a patient What is the rationale for the nurse’s actions? a It allows a nurse to compete with physicians or health care providers b It allows a nurse to develop an individualized plan of care c It allows a nurse to treat nursing problems and medical problems d It allows a nurse to manage patient care for the entire health team ANS: B The diagnostic process results in the formation of a total diagnostic statement that allows a nurse to develop an appropriate, patientcentered plan of care A nursing diagnosis provides direction for nursing, not for medical problems or for the entire health team It is not used to compete with physicians or health care providers PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 136 OBJ: List the steps of the nursing diagnostic process TOP: Nursing Process: Planning Care MSC: NCLEX: Management of 25 A patient is suffering from shortness of breath How should the nurse write the expected outcome for this patient? a “The patient will be comfortable by the morning.” b “The patient will breathe unlabored at 14 to 18 breaths per minute by the end of the shift.” c “The patient will not complain of breathing problems.” d “The patient will appear less short of breath.” ANS: B Each patient outcome contains the following aspects in order to be correctly written: (1) patient-centered, (2) singular, (3) observable, (4) measurable, (5) time limited, (6) mutual factors, and (7) realistic Comfortable is not measurable Outcome that deals with no complaints of breathing is lacking the time limited guideline “Patient will appear less short of breath” is not a correct statement because there is no specific observable behavior for “appears less short of breath.” PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 142 OBJ: Discuss the difference between a goal and an expected outcome TOP: Care 26 Nursing Process: Planning MSC: NCLEX: Management of A nurse is caring for a patient and performs several interventions Which action by the nurse is an independent nursing intervention? a Turning every hours b Administering a medication c Inserting an indwelling catheter d Starting an intravenous (IV) for intravenous fluids ANS: A According to state Nurse Practice Acts, independent nursing interventions pertain to ADLs (turning), health education and promotion, and counseling Nurse-initiated interventions are the independent nursing interventions or actions that nurses initiate Physician-initiated interventions are dependent nursing interventions or actions that require an order from a physician or another health care professional Administering a medication, implementing an invasive procedure (catheter and intravenous fluids), and preparing a patient for diagnostic tests are examples of such interventions PTS: DIF: Cognitive Level: Applying (Application) REF: 143 interventions OBJ: Discuss the process of selecting nursing TOP: Nursing Process: ImplementationMSC: NCLEX: Management of Care 27 A nurse is writing a care plan for a newly admitted patient Which outcome statement did the nurse correctly write? a “The patient will eat 80% of all meals.” b “The nursing assistant will set up the patient for a bath every day.” c “The nursing assistant will ambulate the patient three times a day by May 30.” d “The patient will identify the need to increase dietary intake of fiber by July 4.” ANS: D The patient will identify the need to increase dietary intake of fiber by July is measurable, reliable, valid, and focuses on the patient Expected outcomes are measurable criteria to evaluate goal achievement These measurable effects relate to a change in a patient’s physical condition or behavior that results from individualized nursing interventions Outcomes should be measurable, reliable, valid, suited to the patient, and sensitive to change Eat 80% of meals has no time frame The nursing assistant is not the focus the patient is Also, the nursing assistant will ambulate the patient or set the patient for a bath are interventions, not outcomes PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 141 OBJ: Discuss the difference between a goal and an expected outcome TOP: Care Nursing Process: Planning MSC: NCLEX: Management of 28 A home health nurse is providing care to a patient Which action by the nurse is a physical care technique? a Dressing a patient b Assisting a patient to learn how to shop c Performing range-of-motion exercises d Administering cardiopulmonary resuscitation ANS: C Physical care techniques involve the safe and competent administration of nursing procedures (e.g., inserting a urinary catheter, performing range-of-motion exercises) Dressing a patient is an activity of daily living Shopping is an instrumental activity of daily living Cardiopulmonary resuscitation is a lifesaving measure PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 154 interventions OBJ: Discuss the process of selecting nursing TOP: Nursing Process: ImplementationMSC: NCLEX: Management of Care 29 A nurse is delegating care of patients to the nursing assistant personnel (NAP) and a licensed practical nurse (LPN) Which situation indicates the nurse needs more instruction on delegation? a LPN to change a sterile dressing b NAP to provide skin care c NAP to insert an indwelling catheter d LPN to administer an enema ANS: C The question indicates the nurse made an incorrect delegation assignment An NAP cannot insert indwelling catheter, an LPN or RN can that skill Noninvasive and frequently repetitive interventions such as skin care, ambulation, grooming, and hygiene measures are examples of activities that you assign to NAP such as certified nurse assistants Licensed practical nurses perform these measures in addition to medication administration and many invasive tasks (e.g., dressing care and catheterization) It is appropriate for an RN to delegate, a sterile dressing change and enema to an LPN It is appropriate for an RN to delegate skin care to an NAP PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 155 interventions OBJ: Discuss the process of selecting nursing TOP: Nursing Process: Evaluation Care MSC: NCLEX: Management of 30 A patient has an outcome of ambulating three times a day The patient does not ambulate the entire day What should the nurse next? a Walk the patient b Reassess the patient c Change the goal for the patient d Continue with the plan for the patient ANS: B When there is failure to achieve a goal, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to discover changes the plan needs A complete reassessment of all patient factors relating to the nursing diagnosis and etiology is necessary when modifying a plan The plan cannot continue because the goal was not met The goal cannot be changed and walking the patient cannot occur until reassessment has been completed PTS: DIF: Cognitive Level: Applying (Application) REF: 157 OBJ: Describe how to evaluate nursing interventions selected for a patient TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 31 A patient has met the goals and outcomes mutually agreed upon for improvement of ventilatory status What should the nurse next? a Modify the care plan b Discontinue the care plan c Create a nursing diagnosis that states goals have been met d Reassess the patient’s response to care and evaluate interventions ANS: B After a nurse determines that expected outcomes and goals have been met and evaluation confirms it, the nurse discontinues that portion of the care plan The nurse modifies a care plan when goals are not met Create a nursing diagnosis occurs after assessment, not during evaluation Reassessing the patient occurs if the goals are not met PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 157 OBJ: Describe each step of the nursing process TOP: Nursing Process: ImplementationMSC: NCLEX: Management of Care 32 A nurse is evaluating care for a patient Which action should the nurse take? a Compares patient findings with the goals and outcomes b Determines if interventions were completed c Develops a nursing diagnosis d Writes a care plan ANS: A During evaluation you compare your findings with the goals and expected outcomes set for your patient You conduct an evaluation to determine if expected outcomes are met, not if nursing interventions were completed Develops a nursing diagnosis is the second step of the nursing process (diagnosis), not the last (evaluation) Writes a care plan occurs in the planning phase PTS: DIF: Cognitive Level: Analyzing (Analysis) REF: 156 OBJ: Describe each step of the nursing process TOP: Nursing Process: ImplementationMSC: NCLEX: Management of Care MULTIPLE RESPONSE The nurse is beginning an assessment of a newly admitted patient What are some recommended comprehensive assessment approaches the nurses can use? (Select all that apply.) a Functional Health Patterns b Nursing Diagnosis c Problem-Focused Approach d Nursing Intervention Classification e Nursing Outcome Classification ANS: A, C There are two approaches for a comprehensive assessment Gordon’s Functional Health Patterns involves use of a structured database format, based upon an accepted theoretical framework or practice standard Another approach for conducting a comprehensive assessment is the problem-focused approach The nurse should focus on the patient’s situation and begin with problematic areas By using Nursing Intervention Classification nurses learn the common interventions recommended for the various NANDA-I nursing diagnoses The Nursing Outcome Classification system is a classification system of nursing-sensitive outcomes One of its purposes is to identify, label, validate, and classify nursing-sensitive patient outcomes A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat and occurs after assessment