A nurse inadvertently commits a medication error without the knowledge of other nursing team members. According to Freud, which part of the personality guides the nurse to initiate an Incident Report? 1. Id 2. Ego 3. Libido 4. Superego
4. The superego is concerned with social standards, ethics, self-criticism, moral standards, and conscience. If the nurse initiates an Incident Report, it is the superego that directs the achievement of ego-ideal behavior. If the nurse does not initiate an Incident Report, it is the superego that criticizes, punishes, and causes a sense of guilt.
A nurse gives a resident in a nursing home a choice about which color shirt to wear. Which level need, according to Maslow’s Hierarchy of Needs, has the nurse just met? 1. Self-esteem 2. Physiological 3. Safety and Security 4. Love and Belonging
1. Choosing which color shirt to wear provides a person with the opportunity to make a choice and supports feelings of independence, competence, and self-respect, which all contribute to a positive self-esteem.
Which statement best reflects a principle common to all theories of health, wellness, and illness? 1. Health is synonymous with a sense of well-being. 2. People are able to control factors that affect health. 3. Many variables influence a person’s perception of health. 4. Being able to meet the demands of one’s role is necessary for health
3. There is little consensus about any one definition of health, wellness, and illness. However, all definitions of health, wellness, and illness address the fact that there are a number of factors that influence health.
According to Maslow, which characteristic is least associated with a person who is self-actualized? 1. Is autonomous 2. Is able to see the good in others 3. Has the ability to problem-solve 4. Has an external locus of control continued growth and who has meaning or purpose in life has a sense of well- being, regardless of the severity of disease or infirmity.
4.An external locus of control least describes self-actualized people. People with an external locus of control respond to a reward or recognition that comes from outside the self. People who are self-actualized strive to develop their maximum potential based on motivation from within.
Which concept identified by the nurse is basic to the health-illness continuum model? 1. People can be both healthy and ill at the same time on the continuum. 2. Actualization must be achieved to be on the healthy end of the continuum. 3. When variables are balanced people are in the exact center of the continuum. 4. There is no distinct boundary between health and illness along the continuum.
4. Health and illness are on opposite ends of the health-illness continuum and there is no distinct boundary between health and illness. Only a person can place herself or himself somewhere along the health-illness continuum based on his or her own perceptions about what constitutes health and illness.
A prospective nurse is being interviewed for a job by the nurse manager in an urgent care center. The nurse manager states that the facility adheres to a clinical model of health/illness. Which should the nurse anticipate will be expected of the nurses within this facility? 1. Consider patients as holistic human beings. 2. Make assessment of patients in the physiological domain. 3. Identify the relationship between patients’ beliefs and actions. 4. Recognize if patients are able to perform their role within the family.
2. The clinical model, also known as the medical model, is concerned with the presence or absence of signs and symptoms of illness, disease, or injury. It is a narrow interpretation of health/ illness because the focus is on the identification and treatment of a defect or dysfunction. Urgent care centers are concerned with meeting acute health- care needs.
Freedom from which situation demonstrates a safety and security need in Maslow’s Hierarchy of Human Needs? 1. Pain 2. Hunger 3. Ridicule 4. Loneliness
1. According to Maslow’s Hierarchy of Needs, freedom from pain is considered a safety and security need. Confusion sometimes occurs because other theorists, such as R. A. Kalish, believe that pain should be categorized along with adequate air, food, water, rest/sleep, shelter, elimination, and temperature regulation as a first-level physiological need.
Which statement identifies a basic principle associated with Sigmund Freud and his work? 1. The reality principle reflects man’s need for immediate gratification. 2. Defense mechanisms are a common means of conscious coping. 3. The id controls the personality. 4. No behavior is accidental.
4. Freud believed that all behavior has meaning and called this theory psychic determinism. He believed that every psychic event is determined by prior events. Behavior, mental phenomena, and even dreams are not accidental but rather an expression of thoughts, feelings, or needs that have a relationship to the rest of a person’s life.
Which concept about health do nurses need to appreciate? 1. Perceptions of health vary among cultures. 2. To be considered healthy a person needs to be productive. 3. There must be an absence of illness for a person to be considered healthy. 4. Underlying consensus exists among theorists about the definition of health.
1. Every individual is influenced by family, ethnic, and cultural beliefs and values. These beliefs and values influence a person’s lifestyle through how one perceives, experiences, and copes with health, illness, and disability. The nurse must assess the impact of these influences on the patient’s health and health practices.
A nurse is analyzing information about a patient. Which of the following does Maslow’s Hierarchy of Needs theory help the nurse to identify? 1. Patient’s problem that has top priority 2. Developmental level of the patient 3. Coping patterns of the patient 4. Patient’s health beliefs
1. Patient problems/needs can be ranked in order of ascending importance according to how essential they are for survival using Maslow’s Hierarchy of Needs as a framework. Maslow identifies five levels of human needs. A person must meet lower-level needs before addressing higher-level needs. Physiological needs are first-level needs: air, food, water, sleep, shelter, etc.; safety and security needs are second; love and belonging needs are third; self-esteem needs are fourth; and self-actualization is the fifth-level need.
Which are examples of a health belief? Select all that apply. 1. _____Eating foods that are low in fat 2. _____Accepting grim results of diagnostic tests 3. _____Concluding that illness is the result of being bad 4. _____Recognizing that smoking can cause lung cancer 5. _____Respecting a patient’s decision regarding therapeutic treatment
2. Accepting grim results of diagnostic tests reflects a behavior in response to bad news, rather than a behavior reflecting a health belief. 3. This is an example of a health belief. A health belief is a conviction or opinion that influences health-care practices or decisions. If a person believes that illness is the result of being bad, the person may feel the need to suffer in silence as a form of penance.
A nurse educator is conducting a class about child development for nurses. The nurse reviews the Stages of Moral Development Theory by Lawrence Kohlberg. Place the following patient statements about what motivates them to behave that reflects the reasoning typical of progression through Kohlberg’s stages of moral development.
1. “I was following the rules.”
2. “I did not want to get punished.”
3. “I expected to receive a reward.”
4. “I thought it was the right thing to do.”
5. “I wanted others to see me as a good person.”
6. “I was doing what is acceptable in our community.
2. The first stage of moral development is Obedience and Punishment. The motivation for behavior is fear of negative consequences (e.g., punishment, disapproval).
3. The second stage of moral development is Individualism and Exchange. The motivation for behavior is the desire for a positive consequence (e.g., reward, good result).
5. The third stage of moral development is Interpersonal Relationships. The motivation for behavior is based on pleasing others because it is what others expect.
1. The fourth stage of moral development is Maintaining Social Order. The motivation for behavior is based on following the rules to uphold the law.
6. The fifth stage of moral development is Social Contract and Individual Rights. The motivation for behavior is based on differing beliefs and values but adheres to standards agreed upon by society.
4. The sixth stage of moral development is Universal Principles. Motivation for behavior is based on abstract reasoning, universal ethical principles, and principles of justice.
A nurse is caring for a newly admitted patient. The nurse collects data and reviews the patient’s clinical record. Which level need is the priority for this patient according to Maslow’s Hierarchy of Needs?
1. Physiologic 2. Self-esteem 3. Safety and security 4. Love and belonging
3. Pain is a safety and security level need based on Maslow’s Hierarchy of Needs. Pain relief is the patient’s priority need.
A nurse is explaining mammography screening to a patient. Which level of health- care delivery service does this diagnostic test reflect? 1. Secondary 2. Tertiary 3. Primary 4. Acute
1. Screening surveys and diagnostic procedures are examples of secondary prevention. Secondary prevention is associated with early detection, early and quick intervention, health maintenance, and prevention of complications. The levels of prevention identify three types of prevention that focus on health-care activities, such as primary prevention (avoiding disease through health promotion and disease prevention), secondary prevention (early detection and treatment), and tertiary prevention (reducing complications, rehabilitation, and restoration and maintenance of optimal function).
Which change identified by the nurse will most affect health-care delivery in the United States in the future? 1. Less emphasis will be placed on prolonging life. 2. The proportion of older adults in society will increase. 3. More people will seek health care in an acute care setting. 4. Genetic counseling will dramatically decrease the number of ill infants born.
2. The percentage of older adults in the United States is expected to increase to 20% by the year 2050. Because chronic illness is more prevalent among older adults, additional health-care services will be needed in the future, raising costs.
Which characteristic is unique to the nurse-patient relationship? 1. Patient’s needs are satisfied. 2. There is a social component. 3. Both are working toward a common goal. 4. The nurse is the leader of the health team.
3. When planning patient care, the nurse and patient work together to identify appropriate goals and interventions to facilitate goal achievement.
When the nurse assesses an adult patient, which patient behavior may indicate an unresolved developmental task of infancy? 1.Avoiding assistance from others 2. Rationalizing unacceptable behaviors 3. Being overly concerned about cleanliness 4. Apologizing constantly for small mistakes
1.People who avoid help from others and who would rather do things themselves generally have not completely resolved the developmental task of Trust versus Mistrust during infancy. Rationalizing unacceptable behaviors is a defense mechanism, not an indication of an unresolved developmental task of infancy.
Which patient should the nurse identify is at the greatest risk when taking a drug that has a high teratogenic potential? 1.Older adult man 2. Pregnant woman 3. Four-year-old child 4. One-month-old infant
2. A pregnant woman is at risk. Teratogenic refers to a substance that can cross the placental barrier and interfere with growth and development of the fetus.
Which concept is reflective of Erik Erikson’s Theory of Personality Development? 1.Defense mechanisms help people to cope with anxiety. 2. Moral maturity is a central theme in all stages of development. 3. Achievement of developmental goals is affected by the social environment. 4. Two continual processes, assimilation and accommodation, stimulate intellectual growth.
3.Erik Erikson expanded on Freud’s Theory of Personality Development by giving equal emphasis to the influence of a person’s social and cultural environment. He stressed that psychosocial development depends on an interactive process between the physical and emotional variables during a person’s life at eight distinct stages. Each stage requires resolution of a developmental conflict that has opposite outcomes and that requires interaction within the self and with others in the environment.
A parent tells the nurse in the well-child clinic that the 2-year-old is trying to eat with a spoon and is making a mess. Which should the nurse encourage the parent to do? 1.Praise and encourage the child while eating. 2. Provide finger foods until the child is older. 3. Feed the child along with the child’s attempts at eating. 4. Take the spoon and feed the child until the child is more capable.
1.From 18 months to 3 years of age (Autonomy versus Shame and Doubt), the child strives for independence. Attempts to self-feed should be encouraged and enthusiastically praised even though the child may make a mess. They allow the child to practice and perfect new skills, help to develop fine motor skills, and support control of the self and the environment.
One of the participants attending a parenting seminar asks the nurse teaching the class, “What is the leading cause of death during the first year of life?” Besides exploring the person’s concerns, what should the nurse respond? 1.Sudden infant death syndrome 2. Congenital malformations 3. Unintentional injuries 4. Short gestation
2. The most recent statistics from the National Center for Health Statistics indicate that congenital malformations are ranked first as the leading cause of all infant deaths.
A pediatric nurse is caring for children of a variety of ages. Which group should the nurse anticipate will have the most problems sleeping as a result of multiple complex developmental factors? 1. Infants 2. Toddlers 3. Adolescents 4. Preschoolers
3.Adolescents (12 to 20 years) have more multiple and complex physiological (e.g., puberty), psychological (e.g., self-identity and independence issues), and social (e.g., peer pressure, altered roles, and maturing relationships) milestones than any other stage of development. Anxiety associated with all of these stressors contributes to altered sleep patterns and sleep deprivation. Adolescents generally need 8 to 10 hours of sleep a day; however, adolescents’ sleep needs vary widely.
A nurse is caring for several children on a pediatric unit. Children in which age group should the nurse expect will be most unstable and challenging with regard to the development of a personal identity?
2.Adolescents (12 to 20 years—Identity versus Role Confusion) have more multiple and complex physiological (e.g., puberty), psychological (e.g., self-identity and independence), and social (e.g., peer pressure, altered roles, and maturing relationships) milestones than any other stage of development. The multiplicity of these stressors can have a major impact on the development of the adolescent’s personal identity and sense of self.
Which word describes the process of growth and development? 1.Fast 2. Simple 3. Limiting 4. Individual
4.Although people follow a general pattern, they do not grow and develop at exactly the same rate or extent.
A school nurse is teaching a class of adolescents about nutrition. Which age group should the nurse identify as having the highest energy expenditure and nutrient requirements? 1.End of the life cycle 2. Middle adult years 3. Early adult years 4. First year of life
4.During the first year of life, nutritional needs per unit of body weight are the greatest in comparison to any other time during the life span. Birth weight generally doubles in 4 to 6 months and triples by the end of the first year.
. A nurse determines that according to Erikson, establishing relationships based on commitment mainly occurs in which stage of psychosocial development? 1.Middle-aged adulthood 2. Young adulthood 3. Adolescence 4. Infancy
2.Young adults (18 to 25 years—Intimacy versus Isolation) strive to establish mature relationships, commit to suitable partners, and develop social and work roles acceptable to society.
A nurse is teaching a parenting class at a local community health center. Which common stressor associated with the developmental stage of early childhood (1 to 3 years) should the nurse include?
1. Accepting limited dietary choices
2. Adjusting to a change in physique
3. Responding to life-threatening illness
4. Resolving conflicts associated with independence
4.During early childhood, the child gains independence through learning right from wrong. Independence occurs with guidance from parents as the child learns self-control without feeling shame and doubt. When parents are overly protective or critical, feelings of inferiority will develop.
A nurse is providing dietary teaching to a group of adolescents recently diagnosed with diabetes mellitus. Which factor should the nurse consider that frequently influences food choices by adolescents? 1. Taste 2. Routine 3. Pressure 4. Preference
3. Peers often dictate the dietary choices of adolescents. Fad dieting and demands of socialization that generally involve fast food are common among adolescents.
A nurse is facilitating a mothers’ class, and the women begin discussing experiences that reflect the intellectual development of their children. Each woman describes a situation that reflects one of the stages of Jean Piaget’s theory about logical thinking. Place the situations described in order beginning with the sensorimotor stage and ending with formal operations. 1. “My son touched the radiator and got burned. He’ll never do that again.” 2. “My son is learning math and is getting 100s on his tests. He is so smart.” 3. “My daughter is on the debating team in school. We go to interschool meets.” 4. “My daughter asked an obese lady if she had a baby in her stomach. I was so embarrassed.”
1.The sensorimotor stage (birth to 2 years) is governed by sensations in which simple learning takes place. It progresses from reflex activity, through repetitive behaviors, to imitative behavior. These children are curious, experiment, and learn primarily through trial and error. 4. The preoperational stage (2 to 7 years) involves thinking that is concrete and tangible; these children cannot reason beyond the observable. Also, their thinking is transductive; that is, knowledge of one characteristic is transferred to another. 2. The concrete-operational stage (7 to 11 years) reflects an increasing ability to use symbols and understand relationships between things and ideas. Judgments are made based on what they reason (conceptual thinking) rather than just what they see (preoperational thinking). Also, they develop the concept of conservation; that is, physical factors (e.g., volume, weight, and number) remain the same even though outward appearances may change. 3. The formal operational stage (11 to 15 years) involves thinking that is abstract, theoretical, philosophical, and hypothetical. Thinking is characterized by flexibility, adaptability, and drawing logical conclusions.
A nurse identifies which words as being unrelated to principles of growth and development? Select all that apply. 1._____Unpredictable
1.Growth and development comprise an orderly process that follows a predictable, not unpredictable, path. There are three predictable patterns: cephalocaudal—proceeding from head to toe; proximodistal—progressing from gross motor to fine motor movements; and symmetrical—both sides developing equally. Growth is marked by measurable changes in the physical aspects of the life cycle, and development is marked by behavioral changes that occur because of achievement of developmental tasks and their resulting functional abilities and skills.
4.Growth and development comprise a complex, not simple, process that involves multiple influencing variables, such as genetics, experience, health, culture, and environment.
5. The word static means stationary, stagnant, or fixed. Growth and development are dynamic and progressive.
A school nurse is assessing several school-aged children between the ages of 6 and 12 years. Which assessment of a child requires a further assessment?
1.7-year-old boy (Grew 1 inch in the last year Gained 15 pounds in the last year)
2. 9-year-old girl (Concerned about achieving acceptable grades in school Identifies with other girls in her grade)
3. 11-year-old boy (Appears clumsy Is tall and thin)
4. 12-year-old girl (Concerned about her physical appearance Interested in boys)
1. During the school-aged years, children usually grow approximately 2 inches a year and gain 4.5 to 6 lb a year. This child should be assessed further because of the potential for obesity. Obesity in children is increasing in the United States.
A nurse is caring for a variety of individuals across the life span. Which age groups generally demonstrate an inefficiency of adaptation? Select all that apply.
1._____More than 60 years
2. _____40 to 60 years
3. _____12 to 19 years
4. _____3 to 11 years
5. _____0 to 1 year
1. When a person reaches 60 years of age and older, all physiological systems are less efficient, which reduces compensatory reserve.
5. Infants have immature immune systems and body systems that are still developing. Also, their body’s physiological processes have a limited experiential background on which to draw responses to new stressors. These issues result in an inefficiency of adaptation.
A nurse identifies that an adult has an unresolved developmental conflict associated with adolescence. Which behaviors support this conclusion? Select all that apply.
1._____Being overly concerned about following daily routines 2. _____Requiring excessive attention from others
3. _____Relying on oneself rather than others
4. _____Failing to verbalize a sense of self
5. _____Lacking goals in life
4.A main developmental task of adolescence is being capable of determining “who you are.” An inability to verbalize a sense of self later in life reflects an unresolved conflict of Identity versus Role Confusion.
5.A main developmental task of adolescence is forming a sense of personal identity as a foundation for the tasks of young adulthood, making decisions regarding career choices, and selecting a mate. An adult who has difficulty setting goals in life indicates an unresolved conflict of Identity versus Role Confusion.
A nurse is assessing a 4-year-old child’s growth and development. Which activities should the nurse expect the child to be capable of performing? Select all that apply.
1. _____Dresses self
2. _____Uses toy tools
3. _____Hops on one foot
4. _____Rides a two-wheel bicycle
5. _____Swims using the freestyle stroke
1. Preschool-aged children have the fine motor skills to open and close zippers and buttons.
2. Preschool-aged children have the motor skills necessary to manipulate a toy tool such as a hammer.
3. Preschool-aged children have the gross motor skills and balance to be able to hop and skip on one foot, balance on one foot, and perform a broad jump.
Which word reflects the ability of a person to perceive another person’s emotions accurately?
2. Empathy is the nurse’s ability to have insight into the feelings, emotions, and behavior of the patient.
What is the consequence when the nurse denies a patient the use of a defense mechanism?
1. Causes more anxiety
2. Precipitates withdrawal
3. Facilitates effective coping
4. Encourages emotional growth
1.Defense mechanisms are used to reduce anxiety and achieve or maintain emotional balance. If a nurse identifies reality and does not recognize the patient’s need to use defense mechanisms, the patient will become more anxious, even to the point of panic.
Which defense mechanism is being used when a patient who has just been diagnosed with terminal cancer calmly says to the nurse, “I’ll have to get on the Internet to assess my options”?
1. This scenario is an example of intellectualization. Intellectualization is the use of reasoning to avoid facing unacceptable stimuli in an effort to protect the self from anxiety.
A nurse is caring for a patient who is scheduled for intravenous chemotherapy for cancer. Which defense mechanism is being used when the patient says to the daughter, “Be brave”?
4. This scenario is an example of projection. Projection is attributing thoughts, emotions, motives, or characteristics within oneself to others.
Which situation identified by the nurse reflects the defense mechanism of displacement? 1. A woman is very nice to her mother-in-law whom she secretly dislikes. 2. A man says that he is not so bad, so don’t believe what they say about him. 3. An adolescent puts a poor grade on a test out of her mind when at her after- school job. 4. An older man gets angry with friends after family members attempt to talk with him about his illness.
4.This scenario is an example of displacement. Displacement is the transfer of emotion from one person or object to a person or an object that is more acceptable and less threatening.
Which is the best way for the nurse to support patients’ self-esteem needs across the life span?
1. Employing a positive mental attitude
2. Providing a nonjudgmental environment
3. Encouraging social interaction with others
4. Supporting the use of defense mechanisms
2. When the nurse establishes a nonjudgmental environment and functions without biases, preconceptions, or stereotypes and avoids challenging a patient’s values and beliefs, a patient’s self-esteem is supported.
A woman with diabetes does not follow her prescribed diet and states, “Everyone with diabetes cheats on their diet.” Which defense mechanism does the nurse identify this patient is using?
1. This is an example of rationalization. Rationalization is used to justify in some socially acceptable way ideas, feelings, or behavior through explanations that appear to be logical.
When the nurse analyzes a patient’s statements, which statements best reflect the dimension of self-esteem? Select all that apply.
1. _____“I really like the me that I see"
2. _____“What do I want to achieve?"
3. _____“ How do I appear to others?"
4. _____“I like things my way"
5. _____“I’m OK, you’re OK."
1. This statement best reflects the dimension of self-esteem. Self-esteem is a person’s self-evaluation of one’s own worth or value. A person whose self- concept comes close to one’s ideal self generally will have a high self-esteem.
5. This statement reflects the dimension of self-esteem. By stating “I’m OK,” the person demonstrates self-acceptance.
Which nursing actions demonstrate support of human dignity in the practice of nursing? Select all that apply.
1. _____Maintaining confidentiality of information about patients
2. _____Supporting the rights of others to refuse treatment
3. _____Obtaining sufficient data to make inferences
4. _____Calling patients by their preferred name
5. _____Staying at the scene of an accident
1.Confidentiality respects the patient’s right to privacy, which is a component of human dignity.
4.Calling patients by their given name demonstrates respect for the individual. Avoid names such as “dear,” “sweetie,” “honey,” and “grandma,” or “grandpa,” because they are demeaning and disrespectful.
Which is the primary reason why nurses attend continuing education programs?
1. Update professional knowledge.
2. Network within the nursing profession.
3. Fulfill requirements for an advanced degree.
4. Graduate from an accredited nursing program.
1.Continuing education programs are formal learning experiences designed to update and enhance professional knowledge or skills. This is necessary because of the explosion in information and technology within health care. Some states require evidence of continuing education units (CEUs) for license renewal.
A unit secretary tells the nurse that the primary health-care provider has just ordered a low-calorie diet for a patient who is overweight. Place these nursing interventions in the order in which they should be implemented.
1. Verify the dietary order.
2. Determine food preferences.
3. Teach specifics about a low-calorie diet.
4. Review a meal plan designed by the patient.
5. Assess the patient’s motivation to follow the diet.
1.Verifying the order should be done first because a diet requires a primary health-care provider’s order; following a specific diet is a dependent function of the nurse.
5.Assessing motivation is one of the most important factors influencing learning. The learner must recognize that the need exists and that the need will be addressed through the learning.
2.Determining food preferences is part of nursing assessment. Food preferences can then be included in the teaching plan about the low-calorie diet.
3.Details of the diet can be taught after the order is verified, motivation is determined, and preferences are identified.
4.Evaluation is the final step of teaching. A meal plan designed by the patient requires not just an understanding of the information but an ability to apply the information.
When considering the nursing process, the word “observe” is to “assess” as the word “explore” is to which of the following words?
2.The definitions of the words “observe” and “assess” are similar. Observe means to view something scientifically, and assess means to collect information. The word “analyze” fits the analogy. Explore means to examine. Analysis means to investigate.
Which statement is related to the concept that is central to the nursing process?
1. It is dynamic rather than static.
2. It focuses on the role of the nurse.
3. It moves from the simple to the complex.
4. It is based on the patient’s medical problem.
1. The nursing process is a dynamic five-step problem-solving process (assessment, analysis, planning, implementation, and evaluation) designed to diagnose and treat human responses to health problems.
Which word best describes the role of the nurse when using the nursing process to meet the needs of the patient holistically?
2. When the nurse supports, protects, and defends a patient from a holistic perspective, the nurse functions as an advocate. Advocacy includes exploring, informing, mediating, and affirming in all areas to help a patient navigate the health-care system, maintain autonomy, and achieve the best possible health outcomes.
A nurse teaches a patient to use visualization to cope with chronic pain. Which step of the nursing process is associated with this nursing intervention?
4. This is an example of the implementation step of the nursing process. It is during the implementation step that planned nursing care is delivered.
Which action reflects the assessment step of the nursing process?
1. Taking a patient’s apical pulse rate every 2 hours after being admitted for an episode of chest pain
2. Scheduling a patient’s fluid intake over 12 hours when the patient has a fluid restriction
3. Examining a patient for injury after a patient falls in the bathroom
4. Obtaining a patient’s respiratory rate after a nebulizer treatment
3. This action reflects the assessment step of the nursing process. Assessment involves collecting data via observation, physical examination, and interviewing.
A nurse is caring for a patient with a fever. Which is a well-designed goal for this patient?
1. “The patient will have a lower temperature.”
2. “The patient will be taught how to take an accurate temperature.”
3. “The patient will maintain fluid intake adequate to prevent dehydration.”
4. “The patient will be given aspirin every eight hours whenever necessary.”
3. This is a well-written goal. Goals must be patient centered, specific, measurable, and realistic and have a time frame in which the expected outcome is to be achieved. The words “adequate” and “dehydration” are based on generally accepted criteria against which to measure the patient’s actual outcome. The word “maintain” connotes continuously, which is a time frame.
Which should the nurse do during the evaluation step of the nursing process?
1. Set the time frames for goals.
2. Revise a plan of care.
3. Determine priorities.
4. Establish outcomes.
2. Revising a plan of care takes place in the evaluation step of the nursing process. If during evaluation it is determined that the goal was not met, the reasons for failure have to be identified and the plan modified.
During which step of the nursing process does determining which actions will be employed to meet the needs of a patient occur?
3. The identification of nursing actions designed to help a patient achieve a goal occurs during the planning step of the nursing process.
Which is the primary goal of the assessment phase of the nursing process?
1. Build trust
2. Collect data
3. Establish goals
4. Validate the medical diagnosis
2. The primary purpose of the assessment step of the nursing process is to collect data (information) from various sources using a variety of approaches
Which most directly influences the planning step of the nursing process?
1. Related factors
2. Diagnostic label
3. Secondary factors
4. Medical diagnosis
1. Related factors (i.e., “contributing to” factors, etiology) contribute to the problem statement of the nursing diagnosis and directly impact on the planning step of the nursing process. Nursing interventions are selected to minimize or relieve the effects of the related factors. If nursing interventions are appropriate and effective, the human response identified in the problem statement part of the nursing diagnosis will resolve.
A nurse collects information about a patient. Which should the nurse do next?
1. Plan nursing interventions.
2. Write patient-centered goals.
3. Formulate nursing diagnoses.
4. Determine significance of the data.
4. After data are collected, they are clustered to determine their significance.
When two nursing diagnoses appear closely related, which should the nurse do first to determine which diagnosis most accurately reflects the needs of the patient?
1. Reassess the patient.
2. Examine the related to factors.
3. Analyze the secondary to factors.
4. Review the defining characteristics.
4. The first thing the nurse should do to differentiate between two closely associated nursing diagnoses is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.
Which is the primary reason why a nurse performs a physical assessment of a newly admitted patient?
1. Identify if the patient is at risk for falls.
2. Ensure that the patient’s skin is totally intact.
3. Identify important information about the patient.
4. Establish a therapeutic relationship with the patient.
3. This is the primary purpose of a nursing physical assessment. Data must be collected and then analyzed to determine significance and grouped in meaningful clusters before a nursing diagnosis or plan of care can be made.
A nurse evaluates a patient’s response to a nursing intervention. To which aspect of the nursing process is this evaluation most directly related?
1. To evaluate the effectiveness of a nursing action the nurse must compare the actual patient outcome with the expected patient outcome. The expected outcomes are the measurable data that reflect goal achievement, and the actual outcomes are what really happened.
A nurse concludes that a patient’s elevated temperature, pulse, and respirations are significant. Which step of the nursing process is being used when the nurse comes to this conclusion?
4. During the analysis step of the nursing process, data are critically explored and interpreted, significance of data is determined, inferences are made and validated, cues and clusters of cues are compared with the defining characteristics of nursing diagnoses, contributing factors are identified, and nursing diagnoses are identified and organized in order of priority.
When the nurse considers the nursing process, the word “identify” is to “recognize” as the word “do” is to which of the following words?
4. This is the correct analogy. The words “identify” and “recognize” have the same definition. They both mean the same as that which is known. The words “do” and “implement” both have the same definition. They both mean to carry out some action.
A nurse is collecting subjective data associated with a patient’s anxiety. Which assessment method should be used to collect this information?
4. Interviewing a patient is the most effective data collection method when collecting subjective data associated with a patient’s anxiety. The patient is the primary source for subjective data about beliefs, values, feelings, perceptions, fears, and concerns.
A nurse assesses that a patient has slurred speech and a retained bolus of food in the mouth. The presence of which additional patient assessments should be clustered with this group of signs and symptoms? Select all that apply.
2. The body continuously secretes saliva (approximately 1,000 mL/day) that usually is swallowed. If a patient is having difficulty swallowing, the patient may aspirate saliva, which can cause coughing.
3. The body continuously secretes saliva (approximately 1,000 mL/day) that usually is swallowed. When saliva accumulates and is not swallowed it dribbles out of the mouth (drooling). Drooling in addition to the patient’s other clinical manifestations indicates that the patient may have impaired swallowing.
4. The body continuously secretes saliva (approximately 1,000 mL/day) that usually is swallowed. When saliva accumulates and is not swallowed it makes a bubbling or gurgling sound in the posterior oropharynx as air is inhaled and exhaled.
Nurses use the nursing process to provide nursing care. These statements reflect nursing care being provided to a variety of patients. Place the statements in order as the nurse progresses through the steps of the nursing process, starting with assessment and ending with evaluation.
1. “Did you sleep last night after I gave you the sleeping medication?”
2. “The patient’s clinical manifestations indicate dehydration.”
3. “The patient will have a bowel movement in the morning.”
4. “What brought you to the hospital today?”
5. “I am going to give you an enema.”
4. Objective and subjective data must be collected, verified, and communicated during the assessment step of the nursing process.
2. Data are clustered and analyzed, and their significance is determined, leading to a conclusion about the patient’s condition, during the analysis step of the nursing process.
3.Identifying goals, projecting outcomes, setting priorities, and identifying interventions are all part of the planning step of the nursing process.
5. Planned actions are initiated and completed during the implementation step of the nursing process.
1. Identifying responses to care, comparing actual outcomes with expected outcomes, analyzing factors that affected outcomes, and modifying the plan of care if necessary are all part of the evaluation step of the nursing process.
A nurse is caring for a patient with a urinary elimination problem. Which are accurately stated goals? Select all that apply.
1. _____“The patient will be taught how to use a bedpan while on bedrest"
2. _____“The patient will experience fewer incontinence episodes at night"
3. _____ “The patient will transfer independently and safely to a toilet before discharge.”
4. _____"The patient will be assisted to the commode every two hours and whenever necessary"
5. _____"The patient will experience one or less events of urinary incontinence daily within 6 weeks.”
3. This is a correctly worded goal. Goals must be patient-centered, measurable, realistic, and include the time frame in which the expected goal is to be achieved. The word “independently” indicates that no help is needed, and the word “safely” indicates that no injury will occur. The time frame is “before discharge.”
5. This is a correctly worded goal. Goals must be patient-centered, measurable, realistic, and include the time frame in which the expected goal is to be achieved. The words “one or less event . . . daily” comprise a measurable statement and the words “within 6 weeks” establish a time frame.
Which human responses identified by the nurse are examples of objective data? Select all that apply.
1. _____Irregular radial pulse of 50 beats per minute
2. _____Wheezing on expiration
3. _____Temperature of 99°F
4. _____Shortness of breath
1.A radial pulse is objective information. Objective data are measurable and checkable.
2.The sound of wheezing is objective data because it can be heard by others. Air becomes turbulent when it moves through narrow passages that cause vibration of airway walls, resulting in high-pitched whistling sounds (wheezing).
3. A temperature of 99°F is objective information. Objective data are measurable and can be verified.
Place the following statements that reflect the analysis step of the nursing process in the order in which they should be implemented.
1. Cluster data.
2. Identify conclusions.
3. Interpret clustered data.
4. Communicate conclusion to other health team members.
5. Identify when additional data are needed to further validate clustered data.
1.The first step in the analysis phase of the nursing process is to group and cluster data that appear to have a relationship. The nurse uses indicative reasoning, moving from the specific to the general.
5. The second step in analysis involves gathering additional data to corroborate, substantiate, support, and validate clustered data further.
3. The third step in analysis involves interpreting the data. The nurse uses reasoning based on knowing commonalities and differences and a scientific foundation of knowledge and experiential background to determine if the data cluster is significant.
2. The fourth step in analysis involves the nurse making a conclusion about the clustered and validated data.
4.The fifth step in analysis involves communicating conclusions to other health team members such as a nursing diagnosis in a nursing plan of care.
Which patient statements provide subjective data? Select all that apply.
1. _____“I’m not sure that I am going to be able to manage at home by myself.”
2. _____“ I can call a home-care agency if I feel I need help at home.”
3. _____“What should I do if I have uncontrollable pain at home?”
4. _____“Will a home health aide help me with my care at home?”
5. _____ I’m afraid because I live alone and I’m on my own.”
1.Knowing one’s own abilities is subjective information because it is the patient’s perception and can be verified only by the patient. Subjective data are those responses, feelings, beliefs, preferences, and information that only the patient can confirm.
5.Fear is subjective information because it is the patient’s perception and can be verified only by the patient. Subjective data are those responses, feelings, beliefs, preferences, and information that only the patient can confirm.
Which nursing action reflects an activity associated with the analysis step of the process? Select all that apply.
1. _____Formulating a plan of care
2. _____Identifying the patient’s potential risks
3. _____Categorizing data into meaningful relationships 4.______Designing ways to minimize a patient’s stressors
5.______Making decisions about the effectiveness of patient
2. Potential risk factors are identified during the analysis step of the nursing process. Risk diagnoses are designed to address situations in which patients have a particular vulnerability to health problems.
3. Determining which data are significant or insignificant and then categorizing the meaningful data into clusters of data that are related are parts of the analysis step of the nursing process.
29. A nurse is interviewing a patient. Which patient statements are examples of objective data? Select all that apply.
1. _____“ I am hungry.”
2. _____“ I feel very warm.”
3. _____“ I ate half my lunch.”
4. _____“I have a rash on my arm.”
5. _____“ I have the urge to urinate.”
6. _____ "I vomit every time I eat something.”
3. The amount of food eaten by a patient can be objectively verified. The nurse measures and documents the percentage of a meal ingested by a patient to quantify the amount of food consumed.
4. A rash on a patient’s arm can be objectively verified via inspection.
6.Vomiting is a human response that is observable and the amount vomited can be measured. Vomiting is objective information.
The following statements reflect steps in the nursing process. Place the statements in order as the nurse advances through the steps of the nursing process, beginning with assessment and ending with evaluation.
1. “The patient is encouraged to attempt to defecate after meals.”
2. “The patient reports not having had a bowel movement for 8 days.”
3. “The patient has constipation related to limited mobility and inadequate fluid intake.”
4. “The patient will have a bowel movement within 2 days that is of normal consistency.”
5. “The patient’s stool is still hard and dry 2 days after initiating an increase in fluids and activity.”
2. This statement reflects data collection that occurs in the assessment phase of the nursing process, which is the first step.
3. This statement reflects etiological factors contributing to the nursing diagnosis problem statement, which is “constipation.” This step analyzes the data collected in the assessment phase of the nursing process.
4. This statement is a measurable goal. Identifying goals occurs after the nursing diagnosis is identified.
1.This statement indicates implementation of a planned action that is designed to address the problem statement.
5.Information about a patient’s response to nursing care can be used to compare the patient’s actual outcome with the expect outcome, which is the evaluation phase of the nursing process.
A nurse is interviewing a patient at the change of shift. Which patient statements reflect subjective data? Select all that apply. 1. _____“ When I lift my head up off the bed I feel like vomiting.”
2. _____“ I just went in the urinal and it needs to be emptied.” 3. _____“My pain feels like a 5 on a scale of 0 to 5.”
4. _____“The physician said I can go home today.”
5. _____“ I ate only 50% of my breakfast.”
3. A patient’s perception about a level of pain is subjective information. Subjective data are those responses, feelings, beliefs, preferences, and information that only the patient can confirm.
A may be the underlying cause of the patient’s constipation. Place an X over the word that reflects the step of the nursing process that is functioning.
Determining relationships of data and their significance are associated with the analysis phase of the nursing process.
A patient is transferred from the emergency department to a medical-surgical unit at 6:30 p.m. The nurse arriving on duty at 8 p.m. reviews the patient’s clinical record. Which information documented in the clinical record reflects the evaluation step of the nursing process?
1. Productive cough
2. Seek order for chest physiotherapy
3. No dizziness reported by the patient
4. Acetaminophen 650 mg administered at 5 p.m.
3.This statement reflects an evaluation of the patient’s response to ambulation.
The nurse assesses a patient and collects a variety of data. Identify the human responses that are subjective data. Select all that apply.
1.Nausea is an unpleasant, wave-like sensation in the back of the throat, epigastrium, or abdomen that may lead to vomiting. It is considered subjective data because it cannot be measured by the nurse objectively. It is experienced only by the patient.
3.This is subjective information because it is the patient’s perception and can be verified only by the patient. Subjective data are those responses, feelings, beliefs, preferences, and information that only the patient can confirm.