NSG 100 Exam 1 Flashcards

Question

Since the nursing process is cyclic rather than linear, the nurse knows that as an individual patient’s condition changes the nurse should anticipate what concept? a. The nurse’s thought processes do not have to vary. b. Plans of care are easier to use and do not need modification. c. The accuracy and effectiveness of thought processes must be considered. d. Reflective thought is not necessary since issues tend to be repetitive.

Answer 1

c. The accuracy and effectiveness of thought processes must be considered. Rationale: The nursing process is cyclic rather than linear. As an individual patient’s condition changes, so does the way a professional nurse thinks about that patient’s needs, forcing modification of earlier plans of care. At each step of the nursing process, nurses must consider the accuracy and effectiveness of their thought process. This form of reflective thought is an essential aspect of critical thinking. The evolutionary nature of the nursing process allows nurses to adjust to changing patient needs. Plans of care must evolve as patients’ needs change.

Answer 2

d. Outcome orientation

Answer 3

d. Contact the social worker about community services. Rationale: The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. The nurse would adjust planning to contact the social worker for community resources so the patient can maintain as much independence as possible. The care plan focuses on the patient’s goals. The provider may or may not be able to extend the hospital stay, but even if that were possible, the patient would not be able to stay until all function returned. The nurse does not simply abandon the care plan; the nurse looks for options and adaptations.

Answer 4

a. Assessment Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

Answer 5

c. Subjective data from a primary source Rationale: Objective data consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested. Subjective data are spoken. Primary data consist of information obtained directly from a patient. Secondary data are collected from family members, friends, other health care professionals, or written sources such as medical records and test results.

Answer 6

a. Ineffective airway clearance related to excessive secretions as evidenced by diminished breath sounds. Rationale: There are three types of diagnoses: actual, risk, and opportunities for improvement. Actual diagnoses have three parts: problem, etiology, and signs/symptoms. Risk diagnoses include only the identified need and the risk factors. The Nursing diagnosis, imbalanced nutrition: less than body requirements, is missing the problem, etiology, and signs and symptoms. Impaired physical mobility is missing the evidence. Risk for suffocation should have only two parts: the potential problem and etiology. There are no signs and symptoms if the patient is at risk.

Answer 7

b. History of stroke Rationale: A two-part risk, Nursing diagnostic statement contains only: (1) the patient’s identified need or problem (i.e., NANDA-I Nursing diagnostic label) and (2) factors indicating vulnerability (i.e., risk factors). The risk factor is the history of stroke. The chest discomfort and shortness of breath are symptoms of the current problems and would not be documented as potential or “risk” issues. “Stroke” would be the identified potential problem.

Answer 8

a. Assessment Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient-focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

Answer 9

c. Implementation Rationale: The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient-focused, with specific outcome identification for evaluation purposes. In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

Answer 10

a. Assessment Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient-focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

Answer 11

b. Planning Rationale: During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

Answer 12

b. The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery. Rationale: All short- and long-term goals must be: (1) patient-focused, (2) realistic, and (3) measurable. For example, a patient-focused, realistic, and measurable short-term goal may be written for a patient with the Nursing diagnosis of Activity intolerance: The patient walks to the bathroom without experiencing shortness of breath within 48 hours after surgery.

Answer 13

c. Standing order Rationale: Standing orders are written by physicians and list specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when care is common to a certain type of situation, such as what to do if a patient experiences chest pain or what actions to take after a colonoscopy. Protocols are written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician’s order. Health care agencies have established protocols outlining procedures for admitting patients or handling routine care situations. Clinical pathways, sometimes referred to as care pathways, care maps, or critical pathways, are multidisciplinary resources designed to guide patient care.

Answer 14

a. Proper documentation facilitates communication with all members of the health care team. Rationale: All nursing interventions that are implemented for patients must be documented or charted. In some cases, this may involve checking off an intervention in the patient’s EMR designed to track the effectiveness of specific interventions. Many health care agencies have special requirements for documenting interventions such as the use of physical restraints or pain protocols. Proper documentation of interventions facilitates communication with all members of the health care team and provides an essential legal record. Accurate charting helps to alleviate omissions and repetition of care although it cannot prevent them. Documentation also allows nurses to evaluate the effectiveness of nursing interventions in meeting patient goals and outcomes, which is the final step in the nursing process.

Answer 15

d. Modify the care plan in response to the patient’s condition and wishes. Rationale: Evaluation focuses on the patient and the patient’s response to nursing interventions and goal or outcome attainment. If a goal was not met, the care plan needs to be modified to avoid simply repeating the same actions. Ignoring the patient is not a therapeutic response. The nurse should respect the patient’s fear and assess further without simply documenting that the patient is unwilling.

Answer 16

c. Implementation Rationale: The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers. In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

Answer 17

a. Disturbed body image Rationale: Priority of Nursing diagnoses is determined by the patient’s preference as well as the severity of the symptoms. The patient is concerned about the loss of hair because this will affect body image. For the patient, this is a prime focus. It is possible that the patient may experience nausea as a result of the chemotherapy drugs. The patient will not be able to eat properly if the nausea is not controlled thus decreasing nutritional intake. There is a potential for bleeding as a result of the low platelet count created by the drugs. All of these must be addressed, but the primary diagnosis, in this case, would be body image.

Answer 18

a. Assessment Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

Answer 19

b. “Blood pressure 90/68, apical pulse 102, skin pale and moist.” c. “Lung sounds clear bilaterally, diminished in right lower lobe.” Rationale: Data collected from medical records, laboratory, and diagnostic test results, or physical assessments are objective. Objective data (i.e., signs) consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested. Subjective data (i.e., symptoms) are spoken. Patients’ feelings about a situation or comments about how they are feeling are examples of subjective data. Data shared by a source verbally are considered subjective. Subjective data may be difficult to validate because they cannot be independently and objectively measured.

Answer 20

a. Nursing diagnoses identify actual or potential problems as well as responses to a problem. b. Nursing diagnoses require naming patient problems using Nursing diagnostic labels. Rationale: The Nursing diagnosis identifies an actual or potential problem or response to a problem. Accurate identification of Nursing diagnoses for patients results from carefully analyzing, validating, and clustering related patient subjective (symptoms) and objective (signs) data. If data collection includes inaccurate or inadequate information or if data are not validated or clustered with related information, a patient may be misdiagnosed. Diagnosis in the nursing process requires naming patient problems using Nursing diagnostic labels. Medical diagnoses are labels for diseases, whereas Nursing diagnoses describe a response to an actual or potential problem or life process.

Answer 21

a. Discussion with the patient c. Collaboration with other members of health care team e. Coordination of care as collaborative care Rationale: Establishing short- and long-term goals to address Nursing diagnoses involves discussion with the patient and often requires collaboration with family members and other members of the health care team. Coordinated, team-based patient care is called collaborative care. The patient’s health care team members may include several nurses: the primary care provider; medical or surgical specialists; respiratory therapists; a dietitian; a physical therapist; occupational, music, or art therapists; a spiritual adviser; and social workers. The patient’s primary nurse is often the central figure in coordinating collaborative care.

Answer 22

a. Shake the patient’s hand and allow the patient time to “warm-up.” Rationale: Establishing rapport is paramount to gaining the trust of the patient. The nurse should consider the patient’s generational cohort, which may influence behavior, and willingness to share personal information during the interview process. Veterans (born before 1945) respect authority; are detail-oriented; communicate in a discrete, formal, respectful way; may be slow to warm up; value family and community and accept physical touch as an effective form of therapeutic communication. Baby Boomers (born 1946 to 1964) are optimistic, relationship-oriented, and communicate by using open or direct speech, using body language, and answering questions thoroughly. They expect detailed information, question everything, and value success. Generation X members (born 1965 to 1976) are informal; are technology immigrants; multitask; communicate in a blunt or direct, factual, and informal style; may talk in short sound bites; share information frequently; and value time. Millennials, also called Generation Y (born 1977 to 1994) are flexible; are technologically literate or are technology natives; multitask; communicate by using action verbs and humor; may be brief in the form of texting or e-mail exchanges; like personal attention; and value individuality. Individuals from Generation Z (born 1995 to 2012) are digitally connected, value group work, want immediate feedback, are accepting of others, value honesty, and family, and are entrepreneurial.

Answer 23

b. Establish the name by which the patient prefers to be addressed. Rationale: The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient. During the orientation phase of the interview, the nurse should establish the name by which the patient prefers to be addressed. Some individuals prefer formal titles of respect (e.g., Dr., Mr., Ms., Professor) and the use of surnames, whereas others are comfortable with less formality. How a patient is addressed is the patient’s choice. Demographic data should be collected by asking focused or closed-ended questions. More general information can be gathered by open-ended communication techniques. When feasible, the nurse and the patient should be seated at eye level with each other. In this way, the interaction between the nurse and the patient is horizontal instead of vertical. Standing over someone implies control, power, and authority. The implication of power can result in less-than-optimal data collection and a potential conflict as the patient strives to regain control over the situation.

Answer 24

c. Sit close and leans in slightly toward the patient. Rationale: Nonverbal behaviors of the nurse can influence the information obtained from the patient. Negative nonverbal cues such as distracting gestures (e.g., tapping a pen, swinging a foot, looking at a watch), inappropriate facial expressions, and lack of eye contact communicate disinterest. To establish a trusting relationship with the patient before the physical examination is conducted, the nurse should communicate professionally, sit close and lean in slightly toward the patient, listen attentively and demonstrate appropriate eye contact, smile, and use a moderate rate of speech and tone of voice.

Answer 25

d. “Let me see if you can have something for the nausea and then talk later.” Rationale: If a patient being admitted to the hospital is too ill to interact for an extended period, the interview can be broken into smaller segments. Interviews with patients already hospitalized or established in the health care system are less extensive and more focused on newly identified patient concerns or problems. Ensuring that the patient is comfortable and relaxed is a priority and often takes prior thought and planning by the nurse.

Answer 26

d. Auscultation Rationale: Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity. Inspection involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems. Percussion involves tapping the patient’s skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures. Vibration is reflected by the tissues, and the character of the sound heard depends on the density of the structures that reflect the sound. Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness.

Answer 27

b. Percussion Rationale: Percussion involves tapping the patient’s skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures. Inspection involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems. Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness. Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity. Vibration is reflected by the tissues, and the character of the sound heard depends on the density of the structures that reflect the sound.

Answer 28

c. Palpation Rationale: Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness. Inspection involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems. Percussion involves tapping the patient’s skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures. Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity. Vibration is reflected by the tissues and the character of the sound heard depends on the density of the structures that reflect the sound.

Answer 29

b. A 14-year-old patient having respiratory distress and increasing anxiety Rationale: Triage, a form of emergency assessment, is the classification of patients according to treatment priority. Patients are categorized by the urgency of their condition. Most emergency departments use a five-tier triage system. The five-tier system classifies patients by levels numbered 1 through 5. Level 1 is considered critical: life-threatening conditions require immediate and continuous care such as severe trauma, cardiac arrest, respiratory distress, seizure, or shock. Level 2 emergencies can be imminently life-threatening conditions requiring care within 30 minutes, such as chest pain or major fractures, with severe pain. Level 3 is considered urgent: potentially life-threatening conditions that require care within 30 to 60 minutes, such as minor fractures, lacerations, and dehydration. Level 4 is considered semi-urgent, stable health conditions that require care within 60 to 120 minutes, such as a twisted ankle. Level 5 conditions are non-urgent and lower risk such as cold symptoms.

Answer 30

a. Emergency assessment Rationale: Emergency assessment is a physical examination done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes. Attention is paid to the patient’s airway, breathing, and circulation. Other concerns in the emergent setting are noticeable deformities such as compound fractures, contusions, abrasions, puncture wounds, burns, tenderness, lacerations, bleeding, and swelling. During an emergency, the nurse may never have time to do a complete assessment and may work to stabilize one body system at a time. A focused or clinical assessment is a brief individualized physical examination conducted at the beginning of an acute care setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern. A focused assessment may be conducted when signs indicate a change in a patient’s condition or the development of a new complication. A comprehensive or complete assessment includes a thorough interview, health history, review of systems, and extensive physical head-to-toe assessment, including evaluation of cranial nerves and sensory organs, such as with sight and hearing testing. A complete physical examination may be conducted on admission to a hospital, during an annual physical at the office of a physician or nurse practitioner, or on initial interaction with a specialist.

Answer 31

b. Focused assessment Rationale: A focused or clinical assessment is a brief individualized physical examination conducted at the beginning of an acute care setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern. A focused assessment may be conducted when signs indicate a change in a patient’s condition or the development of a new complication. Emergency assessment is a physical examination done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes. Attention is paid to the patient’s airway, breathing, and circulation. Other concerns in the emergent setting are noticeable deformities such as compound fractures, contusions, abrasions, puncture wounds, burns, tenderness, lacerations, bleeding, and swelling. A comprehensive or complete assessment includes a thorough interview, health history, review of systems, and extensive physical head-to-toe assessment, including evaluation of cranial nerves and sensory organs, such as with sight and hearing testing. A complete physical examination may be conducted on admission to a hospital, during an annual physical at the office of a physician or nurse practitioner, or on initial interaction with a specialist

Answer 32

a. “My last bowel movement was 4 days ago.” Rationale: Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms. Objective data, also referred to as signs, can be measured or observed. The nurse’s senses of sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results.

Answer 33

d. Secondary, subjective data Rationale: Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms. Family members, friends, and other members of the health care team can contribute valid secondary, subjective data. Objective data also referred to as signs, can be measured or observed. The nurse’s senses of sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results. Primary data come directly from the patient.

Answer 34

b. Primary, subjective data Rationale: Primary data come directly from the patient. Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms. Family members, friends, and other members of the health care team can contribute valid secondary, subjective data. Objective data also referred to as signs, can be measured or observed. The nurse’s senses of sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results.

Answer 35

c. “I will go visit her right away and see what is going on.” Rationale: Validating data is making sure that the data are accurate. As patient information is collected, consistency between subjective and objective data must be confirmed. Confirming the validity of collected data often requires verbally checking with the patient to see whether the assumptions or conclusions at which the nurse arrived are correct. Crying, a disheveled appearance and lack of eye contact may be cues of depression. However, conclusions about the underlying cause of the patient’s actions cannot be assumed. All cues need to be interpreted and validated to verify the data’s accuracy. The nurse cannot assume that this is normal behavior nor ignore the problem by making a joke. The nurse has the responsibility to attempt to determine the real reason for the crying episode.

Answer 36

b. Review the lab results of the most recent urinalysis. Rationale: As patient information is collected, consistency between subjective and objective data must be confirmed. Sometimes, the nurse can use laboratory and diagnostic test results to validate the subjective data. In this case, checking the urinalysis for congruency with the patient’s subjective data will validate the patient’s statements. Obtaining a set of vital signs, reviewing the patient’s history, and exploring the patient’s pain are appropriate actions but cannot validate the current problem.

Answer 37

b. Ask the patient what information the surgeon has explained about the surgery. Rationale: Careful observation and attention to detail help the nurse to notice subtle cues and recognize how best to validate and interpret patient data. The nurse must be careful not to make false assumptions or generalizations regarding the patient’s responses to the health concern. The nurse is correct to ask the patient about the upcoming surgical procedure instead of assuming that the patient has limited knowledge. This is the nurse’s best action to determine what the surgeon said to the patient. Developing a comprehensive teaching plan is not necessary until further clarification is obtained. Focusing on postoperative treatment plans is important but not the priority at this time. It is not appropriate to contact the surgeon unless the patient demonstrates an actual knowledge deficit.

Answer 38

b. Functional Health Patterns Rationale: Marjory Gordon developed the Functional Health Patterns to help nurses focus on patient strengths and related but sometimes overlooked data relationships. This method of organizing patient data is a more holistic approach than the others because it includes data such as values, beliefs, and roles in addition to physical data. Organizing assessment data in a head-to-toe (cephalic-caudal) pattern ensures that all areas of concern are addressed as the nurse performs an assessment covering the entire body. The body systems model organizes data on the basis of each system of the body: integumentary, respiratory, cardiovascular, nervous, reproductive, musculoskeletal, gastrointestinal, genitourinary, and immune systems. It follows a sequence similar to the medical model for physical examination. The body systems model for data organization tends to focus on the physical aspects of a patient’s condition rather than a more holistic view.

Answer 39

a. Demographic data b. Patient’s allergies c. Family history of diseases d. Patient’s health promotion practices e. Patient’s history of illness and surgery Rationale: An in-depth health history includes all pertinent information that can guide the development of a patient-centered plan of care. The health history includes demographic data, which are collected during the orientation phase of the interview; a patient’s chief complaint or reason for seeking health care; history of current and past illnesses and surgery; allergies; medications; adverse reactions to medications; medical history; family and social history; and health promotion practices. Because a patient’s health history is continuously evolving, the data collection is ongoing, progressive, and methodical.

Answer 40

b. Gather information about what the patient already knows about diabetes. c. Have the patient demonstrate checking a blood glucose level. Rationale: Data that would validate the nurse’s suspicion that the patient needs further education include determining what the patient already knows about diabetes and having the patient demonstrate the technique of blood glucose monitoring. If the nurse is correct, further education is needed. Before further education can occur however; the nurse should determine if the patient has cognitive difficulties or a language barrier which would all contribute to an individualized plan of care. Reading material should typically be written at a fifth-grade level, but the nurse should not assume the patient needs third-grade level material.

Answer 41

a. Blood test results b. X-ray results c. Recent vital signs Rationale: On completion of the patient interview, health history, and review of systems, the nurse begins the physical assessment. During the physical assessment, the nurse collects objective data. If diagnostic tests, such as blood tests or x-rays, were ordered before the patient was seen, the results are reviewed by the nurse. Vital signs are taken and recorded at the beginning of the physical examination.

Answer 42

a. A 28-year old patient scheduled to be discharged home today b. A 49-year-old patient with stable chronic lung disease d. A 35-year-old patient waiting for transfer to a rehabilitation center Rationale: Routine assessment of vital signs of a patient who is stable may be delegated to licensed practical or licensed vocational nurses (LPNs/LVNs) or qualified UAP. Initial and ongoing assessment of patients requiring critical care or who are unstable cannot be delegated to UAPs. The patient with rectal bleeding may need critical care, and a new admission needs to be assessed by an RN. Stable patients such as patients with stable lung disease or awaiting discharge or transfer can be delegated to UAP.

Answer 43

a. Respirations—24 breaths/min b. Platelet count—350,000 mm3 c. Wound size—3 cm × 2 cm d. Temperature—98.4 °F (36.8 °C) Rationale: Objective data, also referred to as signs, can be measured or observed. The nurse’s senses of sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results. Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms.

Answer 44

a. Have an understanding of patient preferences. b. Be aware of family values. c. Recognize the patient’s expectations. Rationale: Patient-centered care requires the nurse to understand patient and family preferences and values. Nurses must recognize patients’ expectations for care and provide care with respect for the diversity of human experience. While interpreting data, the nurse must be careful to avoid inaccurate inferences (i.e., conclusions) based on the nurse’s personal preferences, past experiences, generalizations, or outdated and inaccurate health care information.

Answer 45

a. Analyze and cluster the assessment information. Rationale: Nursing diagnosis is the second step of the nursing process. Formulation of nursing diagnoses follows patient data collection and involves the analysis and clustering of related assessment information. Actual nursing diagnoses identify existing problems or concerns of a patient. Risk nursing diagnoses apply when there is an increased potential or vulnerability for a patient to develop a problem or complication. Health-promotion nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. The analysis of information is required to determine nursing diagnoses.

Answer 46

c. Health-promotion Rationale: Health-promotion nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. Although most nursing diagnoses are used for individual patients, nursing diagnosis taxonomy can be applied to families, groups of individuals, and communities. Actual nursing diagnoses identify existing problems or concerns of a patient. Risk (potential) nursing diagnoses apply when there is an increased potential or vulnerability for a patient to develop a problem or complication.

Answer 47

a. Pericarditis Rationale: Whereas medical diagnoses identify and label medical (physical and psychological) illnesses, nursing diagnoses are much broader in and consider a patient’s response to medical diagnoses and life situations. The underlying etiology, or cause of a patient’s concern or situation, rather than a medical diagnosis, should be used as a related factor when writing an ICNP nursing diagnosis statement and can be included in the list of supporting data in the EMR. Pericarditis is a medical diagnosis defined as an inflammation of the pericardium. Pain, anxiety and intolerance to activity are all possible patient responses to the medical condition of pericarditis.

Answer 48

a. Risk Rationale: The three types of nursing diagnostic statements are actual, risk, and health promotion. Determining which type is needed for each patient can be challenging. Risk (potential) Nursing diagnoses apply when there is an increased potential or vulnerability for a patient to develop a problem or complication. Actual Nursing diagnoses identify existing problems or concerns of a patient. Health-promotion Nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. Although most nursing diagnoses are used for individual patients, nursing diagnosis taxonomy can be applied to families, groups of individuals, and communities. Medical diagnoses identify and label medical (physical and psychological) illnesses.

Answer 49

d. Impaired airway clearance related to muscle weakness. Rationale: Each type of Nursing diagnostic statement contains sections or parts. Actual Nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics. Risk Nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion Nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics. The impaired airway clearance label is missing the defining characteristics.

Answer 50

c. Pressure on lumbar spinal nerves Rationale: The second part of the Nursing diagnosis consists of related factors (for actual Nursing diagnoses) and risk factors (for risk Nursing diagnoses). Related factors are the underlying cause or etiology of a patient’s problem. Risk factors are environmental, physical, psychological, or situational concerns that increase a patient’s vulnerability to a potential problem or concern. In this case, the acute pain is being caused by pressure on the lumbar spinal nerves.

Answer 51

d. Risk for constipation related to insufficient physical activity. Rationale: Each type of Nursing diagnostic statement contains sections or parts. Actual Nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics. Risk Nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion Nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics. There are no data suggesting the patient is constipated at this time.

Answer 52

a. “The defining characteristics will include the patient’s willingness to get better.” Rationale: The three types of Nursing diagnostic statements are actual, risk, and health promotion. Determining which type is needed for each patient can be challenging. Health-promotion Nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. The second part of the Nursing diagnosis consists of related factors (for actual Nursing diagnoses) and risk factors (for risk Nursing diagnoses). Related factors are the underlying cause or etiology of a patient’s problem. Risk factors are environmental, physical, psychological, or situational. Health-promotion Nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics. Actual diagnoses describe the person, family, or community’s response to a health condition or life process that already has occurred. “Ineffective community coping” would be an example of an actual problem.

Answer 53

c. Evaluate the data looking for patterns and related data. Rationale: After collecting and reviewing all of the assessment data, the nurse looks for patterns and related data to support specific Nursing diagnoses. This process is referred to as clustering data. Clustering involves organizing patient assessment data into groupings with similar underlying causes. All patient information should be considered as potentially contributing to the identification of diagnostic labels. This information includes subjective and objective data collected through physical assessment of the patient, interview of the patient and family members, and laboratory and diagnostic test results, including x-rays, physicians’ orders, and documentation from health care providers. Verifying specific Nursing diagnoses for a patient or situation follows accurate analysis and clustering of data.

Answer 54

d. Blood pressure, pulse rate, blood volume, mental status, dehydration Rationale: All patient information should be considered as potentially contributing to the identification of diagnostic labels. This information includes subjective and objective data collected through physical assessment of the patient, interview of the patient and family members, and laboratory and diagnostic test results, including x-rays, physicians’ orders, and documentation from health care providers. Verifying specific Nursing diagnoses for a particular patient or situation follows accurate analysis and clustering of data.

Answer 55

d. Constipation, weight gain Rationale: Clustering involves organizing patient assessment data into groupings with similar underlying causes. The nurse looks for cues among the data that support the diagnosis of a problem. One patient may have several problems simultaneously, requiring the nurse to understand the potential relatedness of signs and symptoms from various body systems. The nurse combines an understanding of pathophysiology, normal structure and function, disease processes, and symptomatology to accurately cluster data. A person who has not had a bowel movement may experience weight gain. Skin, nails, and hair are components of the integumentary system. The subjective feelings of tired and cold are related and prolonged menstruation, as part of the reproductive system, is in a group by itself.

Answer 56

a. Clustering unrelated data in the diagnostic statement Rationale: A variety of errors in identification, statement structure, and statement content may occur when formulating Nursing diagnoses. These include clustering unrelated data, accepting erroneous data, missing the true underlying etiology of a problem, using medical diagnoses as related factors in a NANDA-I Nursing diagnostic statement, and identifying multiple Nursing diagnosis labels in one NANDA-I Nursing diagnostic statement. Clustering unrelated data most often occurs when the nurse has not completed a thorough review of the patient’s assessment information or is missing important data. The nurse assumes the patient is not taking the blood pressure medication because of the cost and chooses the diagnosis of noncompliance. The nurse fails to ask the patient if the medication is being taken as ordered. Errors in data collection (e.g., omitting key information) or an incomplete understanding or knowledge of assessment techniques or a patient’s condition may lead to the inclusion of erroneous data in a Nursing diagnostic statement. When writing Nursing diagnoses, the nurse should avoid inclusion of more than one label in the statement. Regardless of the type of Nursing diagnosis being written, only one label should be used in each statement. The nurse does not commit this error here. “Lack of knowledge” is not a medical diagnosis.

Answer 57

c. Abdominal pain and nausea related to inflammation. Rationale: One patient may have several problems simultaneously, requiring the nurse to understand the potential relatedness of signs and symptoms from various body systems. The nurse combines an understanding of pathophysiology, normal structure and function, disease processes, and symptomatology to accurately cluster data. Abdominal pain, nausea, and inflammation (of the intestines) are clustered together.

Answer 58

c. Impaired sleep and lack of knowledge related to stress as evidenced by patient report of difficulty sleeping and lack of energy. Rationale: To correctly formulate a nursing diagnostic statement, the student needs to cluster related data and choose one diagnosis per statement. In the incorrect example, two nursing diagnoses were combined in one statement.

Answer 59

c. It is the underlying etiology of the patient’s situation. Rationale: The underlying etiology, or cause of a patient’s concern or situation, rather than a medical diagnosis, should be used as a related factor when writing a Nursing diagnosis. By doing so, the nurse articulates an understanding of the pathophysiology or situation with which the patient is faced.

Answer 60

a. The nurse is ultimately responsible for assessment of patient needs and progress. Rationale: Even though collaboration and delegation may occur, the nurse is ultimately responsible for the continued assessment of patient needs and progress. As delegator, the nurse must supervise other disciplines to make sure that the patient needs are being met. Detection of additional problems or lack of progress with the patient should prompt the nurse to reconsider the nursing process steps.

Answer 61

d. The nurse facilitates communication of patient needs and promotes accountability. Rationale: The use of Nursing diagnosis labels facilitates clear communication of patient needs and promotes professional accountability and autonomy by defining and describing the independent area of nursing practice. Nursing diagnostic statements clearly communicate to legislators, consumers, and insurance providers the unique care nurses deliver and the specific nature of the health conditions they treat. Use of a unified language classification system, or taxonomy, is an effective vehicle for communication among nurses and other health care professionals.

Answer 62

a. Lack of muscle motor movement Rationale: The related factor in an actual Nursing diagnosis needs to address the underlying etiology of the patient’s problem expressed by the Nursing diagnostic label rather than listing data that are defining characteristics. The decreased sensation to touch, inability to speak clearly, and pain in the back of the head are only reiterations of the defining characteristics (numbness in face, slurred speech, and headache).

Answer 63

a. Develop multiple Nursing diagnoses. Rationale: Analysis of patient assessment data may yield several clusters of related data or cues. It is common to apply several Nursing diagnostic statements to one patient. This is especially true for acutely ill patients with multiple problems related to complex physical or psychological needs.

Answer 64

a. Acute pain b. Risk for impaired walking c. Ineffective bone tissue perfusion Rationale: Whereas medical diagnoses identify and label medical (physical and psychological) illnesses, Nursing diagnoses are much broader in focus. Nursing diagnoses consider a patient’s response to medical diagnoses and life situations in addition to making clinical judgments based on a patient’s actual medical diagnoses and conditions. Pain, potential inability to ambulate, and decreased blood flow to the bone are a patient’s response to the medical condition of osteomyelitis. Medical diagnoses identify the specific physical or psychological condition. Osteomyelitis and infection are medical diagnoses defined as inflammation and an infection of the bone usually caused by bacteria.

Answer 65

b. Risk for injury related to hallucination d. Impaired socialization related to excessive stimulation of nervous system as evidenced by unintelligible speech. Rationale: Each type of Nursing diagnostic statement contains sections or parts. Actual Nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics. Risk Nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion Nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics. The first statement needs defining characteristics. Insomnia is a medical diagnosis. The last statement needs etiology and manifestations

Answer 66

a. Acute pain b. Fear Rationale: One patient may have several problems simultaneously, requiring the nurse to understand the potential relatedness of signs and symptoms from various body systems. The nurse combines an understanding of pathophysiology, normal structure and function, disease processes, and symptomatology to accurately cluster data. The patient is reporting severe chest pain with an inability to take deep breaths. The Nursing diagnostic label of acute pain is appropriate. Being scared is a defining characteristic of the Nursing diagnosis of fear. The patient is not at risk for aspiration or infection based on the data presented.

Answer 67

a. Patient satisfaction b. Positive patient outcomes c. Quality patient care e. Determine appropriate interventions Rationale: Ultimately, nurses are accountable for formulating accurate Nursing diagnoses and intervening appropriately. By collecting accurate and complete assessment data and articulating concise Nursing diagnoses for each patient, the professional nurse has a significant impact on patient care outcomes, the quality of patient care, and patient satisfaction. By identifying and writing clear Nursing diagnostic statements, the nurse enables accurate development of individualized patient plans of care. Nursing diagnoses and patient outcomes, which are established during the planning step, help the nurse to determine appropriate interventions for patient care.

Answer 68

a. Threats of killing oneself b. Chronic pain c. History of prior suicide attempt d. Loneliness Rationale: Risk factors may be environmental, physical, psychological, or situational concerns. The nurse is concerned that the patient may be at risk for suicide. Verbal statements by the patient, physical illness such as chronic pain, prior attempts to commit suicide and a lack of social interaction are potential causes for the act of suicide. A stable heart rhythm would not be a safety concern.

Answer 69

a. Pain Rationale: Using Maslow’s hierarchy of needs helps to organize the most-urgent to less-urgent needs. This framework organizes patient data according to basic human needs common to all individuals. Maslow’s theory suggests that basic needs, such as physiologic needs, must be met before higher needs, such as self-esteem. The nurse also realizes that an actual problem takes priority over a potential problem. By using the nursing process appropriately, the nurse correctly chooses the actual, physiological problem first: pain. Once the patient has the morphine, the risk for falls becomes a higher priority than knowledge deficit or alteration in body image because the morphine might confuse the patient, cause dizziness or faintness, and lead to a fall.

Answer 70

a. Monitoring patient responses Rationale: Setting priorities among identified Nursing diagnoses is the first step in the planning process. The nurse is responsible for monitoring patient responses, making decisions culminating in a plan of care, and implementing interventions, including interdisciplinary collaboration and referral, as needed. The nurse is significantly accountable for achieving the desired outcomes.

Answer 71

c. Shortness of breath Rationale: It is essential that the nurse identify life-threatening concerns and patient situations that need to be addressed most quickly. The ABCs—airway, breathing, and circulation—are a valuable tool for directing the nurse’s thought process. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds. For instance, if a patient is in respiratory arrest, the most critical goal is for the patient to begin breathing. The reddened coccyx, decreased urinary output, and surgical incision drainage is not immediately life-threatening.

Answer 72

d. Absence of pulse Rationale: It is essential that the nurse identify life-threatening concerns and patient situations that need to be addressed most quickly. The ABCs—airway, breathing, and circulation—are a valuable tool for directing the nurse’s thought process. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds. In this situation, the patient needs CPR immediately due to the absence of a pulse. Pain, hunger, and decreased self-esteem are not life-threatening issues. Although the nurse must address them, pulselessness is the priority.

Answer 73

a. “Patients should be included in the planning process.” Rationale: Planning is the third step of the nursing process. During the planning phase, the professional nurse prioritizes the patient’s Nursing diagnoses, determines short- and long-term goals, identifies outcome indicators, and lists nursing interventions for patient-centered care. Patients should be included in the planning process. Involving patients in planning their care helps them to: (1) be aware of identified needs, (2) accept realistic and measurable goals, and (3) embrace interventions to best achieve the mutually agreed-on goals. Inclusion of patients in the planning process tends to improve goal attainment and patient cooperation with interventions. Depending on the patient’s condition or circumstances, it may be advantageous to include members of the patient’s support system (i.e., family, friends, and caregivers) in the planning phase.

Answer 74

c. They are mutually acceptable to the nurse, patient, and family. Rationale: Goals are broad statements of purpose that describe the aim of nursing care. Goals represent short- or long-term objectives that are determined during the planning step. Some sources establish time parameters for short- and long-term goals, whereas others do not. According to Carpenito, goals that are achievable in less than a week are short-term goals, and goals that take weeks or months to achieve are long-term goals. Useful and effective goals have certain characteristics. They are mutually acceptable to the nurse, patient, and family. They are appropriate in terms of nursing and medical diagnoses and therapy. The goals are realistic in terms of the patient’s capabilities, time, energy, and resources, and they are specific enough to be understood clearly by the patient and other nurses. They can be measured to facilitate evaluation.

Answer 75

a. Develops the goals with the patient and possibly the family. Rationale: The nurse creates goals with the patient and possibly with the family by discussing the patient’s current condition, the condition to which the patient wants to progress, and the actions the patient and nurse undertake to accomplish the goal. If the goals are simply what the nurse wants the patient may have other goals in mind to which he or she gives more attention and effort. The goal does not include the interventions or actions needed; however they must be discussed so the patient understands the care he or she is to receive and what part the patient plays in achieving the goals. The nurse works with the patient to develop a plan of care that is appropriately challenging and promotes patient success in attaining goals.

Answer 76

b. High numbers of minority populations do not understand health teachings. Rationale: Minority patients globally and those with low English proficiency in the United States are especially vulnerable to low health literacy. Patients of both genders, including those who are well educated and highly literate but have limited health care experience, may struggle with the complexity of health care terminology and procedures. Older adults have also been identified as a group experiencing low health literacy. Before implementing teaching strategies to support goal attainment, the nurse must explore a patient’s disabilities and the effects they may have on achieving specific goals. Successful accommodation of a patient’s disabilities should yield attainable goals that lead to positive outcomes.

Answer 77

d. The patient will eat 75% of all meals for the next three days. Rationale: According to Carpenito, goals that are achievable in less than a week are short-term goals, and goals that take weeks or months to achieve are long-term goals. Eating 75% of all meals for the next three days is an example of a short-term goal. A goal set for 6 weeks or a year in the future is a long-term goal. The ambulation goal has no time determination; therefore it can’t be labeled as either short- or long-term and as such, is incorrectly written.

Answer 78

b. Patient will ambulate 100 feet with no shortness of breath on third day after treatment. Rationale: Useful and effective goals have certain characteristics. They are appropriate in terms of nursing and medical diagnoses and therapy. The goals are realistic in terms of the patient’s capabilities, time, energy, and resources, and they are specific enough to be understood clearly by the patient and other nurses. They can be measured to facilitate evaluation. In option A, there is no time frame to gauge expectations, so the diagnosis is not measurable. In option C, the number of stairs is not specified and so is not measurable. In option D, the type of activity is not mentioned, so it is not specific and there is no measurable criterion.

Answer 79

a. The effects of pain and/or clinical depression Rationale: Pain and depression both can lead the patient away from cooperation and motivation in working towards goal achievement. The nurse must address either problem in order to have the best chance of success for the patient in meeting goals. Patient and family involvement help create “buy-in” and cooperation. Realistic expectations lead to reasonable and achievable goals.

Answer 80

d. The patient will ambulate 10 feet by postoperative day 2. Rationale: Patient-centered goals are written specifically for the patient. The goal should specify the activity the patient is to exhibit or demonstrate to indicate goal attainment. These goals are written to reflect patient, not nursing, activities. Instead of focusing on the patient, the incorrect answers focus on the patient’s temperature, the nurse medicating the patient, and the patient’s skin integrity. Only option D focuses on the patient.

Answer 81

a. “The patient will be able to lift 10 lb. by the end of week one.” Rationale: Measurable goals are specific, with numeric parameters or other concrete methods of judging whether the goal was met. When writing a goal statement with a patient, the nurse needs to clearly identify how achievement of the goal will be evaluated. When terms such as acceptable or normal are used in a goal statement, goal attainment is difficult to judge because they are not measurable terms, unless they refer to laboratory values or diagnostic test findings. The amount of weight a patient will lift at the end of the week is not specified. “Normal” and “acceptable” weight have not been defined.

Answer 82

c. They depend on intervention and patient condition. Rationale: In most cases, goal statements need to include a time for evaluation. The time depends on the intervention and the patient’s condition. Some goals may need to be evaluated daily or weekly, and others may be evaluated monthly. The health care setting affects the time of evaluation. If the goal is set during hospitalization, the goal may need to be evaluated within days, whereas a goal set for home care may be evaluated weekly or monthly. At the time of evaluation, the goal is assessed for goal attainment, and new goals are set or a new evaluation date for the same goal may be chosen if the goal is still applicable for the patient care plan.

Answer 83

a. They need to be individualized for each patient. Rationale: There are multiple formats in which to develop individualized care plans for patients, families, and communities. Each health care agency has its own form, including electronic formats, to facilitate the documentation of patient goals and individualized patient-centered plans of care. All formats contain areas in which the nurse identifies key assessment data, Nursing diagnostic statements, goals, interventions for care, and evaluation of outcomes. In many agencies and specialty units, standardized care plans that must be individualized for each patient are available to guide nurses in the planning process.

Answer 84

a. Dependent Rationale: Interventions originating from a provider’s order are dependent nursing interventions. Independent nursing interventions are originated by the nurse based on expertise in meeting patient needs or preventing complications. Interventions that include collaboration with other providers, such as physical therapy, are collaborative interventions. Nursing Interventions Classification (NIC) is a research-based, standardized collection of interventions and associated activities.

Answer 85

b. Dependent Rationale: Interventions originating from a provider’s order are dependent nursing interventions. Independent nursing interventions are originated by the nurse based on expertise in meeting patient needs or preventing complications. Interventions that include collaboration with other providers, such as physical therapy, are collaborative interventions. Collaborative interventions require cooperation among a few or many members of the interdisciplinary health care team.

Answer 86

d. Oxygen administration via mask Rationale: Dependent nursing interventions originate from health care provider orders. These interventions include orders for oxygen administration, dietary requirements, medications and diagnostic tests. The nurse incorporates these orders into the patient’s overall care enact independent interventions has expanded in recent years, allowing nurses to initiate care that they recognize as essential in meeting patient needs or preventing complications. Utilizing heel protectors for patients susceptible to skin breakdown and initiating preventive measures (e.g., activity regimens, consultations with social workers, preadmission teaching) are often independent, nurse-initiated interventions. Collaborative interventions require cooperation among several health care professionals and unlicensed assistive personnel (UAP). Collaborative interventions include activities such as physical therapy, home health care, personal care, spiritual counseling, medication reconciliation, and palliative or hospice care.

Answer 87

a. Collaborative interventions Rationale: Interventions that include collaboration with other providers, such as physical therapy, are collaborative interventions. Interventions originating from a provider’s order are dependent nursing interventions. Independent nursing interventions are originated by the nurse based on expertise in meeting patient needs or preventing complications. An assessment is done to gather data.

Answer 88

b. Upon admission Rationale: Discharge planning plays an important role in the success of a patient’s transition to the home setting after hospitalization. Because most patients are in the hospital for only a short time, nurses must begin discharge planning on admission and continue until a patient is dismissed.

Answer 89

a. “It may decrease the incidence of patients who need to return to the hospital.” Rationale: Research shows that comprehensive discharge planning reduces complications and readmissions. Home care planning adapts to the situation as the patient’s condition improves or deteriorates as a result of advancing disease. Because most patients are in the hospital for only a short time, nurses must begin discharge planning on admission and continue until a patient is dismissed.

Answer 90

a. Prioritizing patient needs b. Developing mutually agreed-on goals c. Determining outcome criteria d. Identifying interventions Rationale: The significance of developing organized plans of care for patients cannot be stressed enough. The nurse must take seriously the responsibility of prioritizing patient needs, developing mutually agreed-on goals, determining outcome criteria, and identifying interventions that can help patients to achieve positive outcomes. After these actions are completed in the planning phase of the nursing process, it is time for implementation of the patient’s plan of care (implementation phase).

Answer 91

a. Prioritize Nursing diagnoses. b. Determine short- and long-term goals. c. Identify outcome indicators. d. List nursing interventions. Rationale: Planning is the third step of the nursing process. During the planning phase, the professional nurse prioritizes the patient’s Nursing diagnoses, determines short- and long-term goals, identifies outcome indicators, and lists nursing interventions for patient-centered care. Each of these actions requires careful consideration of assessment data (collected earlier) and a thorough understanding of the relationship among Nursing diagnoses, goals, and evidence-based interventions.

Answer 92

a. Being aware of identified needs c. Embracing mutually agreed-on goals d. Feeling a sense of empowerment Rationale: Patients should be included in the planning process. Involving patients in planning their care helps them to: (1) be aware of identified needs, (2) accept realistic and measurable goals, and (3) embrace interventions to best achieve the mutually agreed-on goals. Inclusion of patients in the planning process tends to improve goal attainment and patient cooperation with interventions. By accepting guidance and input from patients during the planning process, the nurse provides them with a greater sense of empowerment and control.

Answer 93

a. Specific b. Concrete d. Easy to judge Rationale: Measurable goals are specific, with numeric parameters or other concrete methods of judging whether the goal was met. When writing a goal statement with a patient, the nurse needs to clearly identify how achievement of the goal will be evaluated. When terms such as acceptable or normal are used in a goal statement, goal attainment is difficult to judge because they are not measurable terms, unless they refer to laboratory values or diagnostic test findings.

Answer 94

a. Administration of an injection Rationale: Direct care refers to interventions that are carried out by having personal contact with patients. For example, direct-care interventions include cleaning an incision, administering an injection, ambulating with a patient, and completing patient teaching at the bedside. Indirect care includes nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients. Examples of indirect care include making the change-of-shift report, communicating and collaborating with members of the interdisciplinary health care team, and ensuring availability of needed equipment.

Answer 95

a. RNs are responsible for all care delegated to unlicensed nursing personnel. Rationale: Delegation is the transfer of responsibility for performing a task to another person while the nurse who delegated the task remains accountable. Delegation is an indirect intervention based on assessment findings and established care priorities. Nurses must be familiar with the nurse practice act in their practice jurisdiction to ensure legal delegation. The nursing process cannot be delegated. In most jurisdictions, LPNs function in a dependent role and may not delegate.

Answer 96

c. Check the provider orders for all forms of prescription medications. Rationale: All forms of prescription medication (i.e., oral, topical, and parenteral) require an order before administration, as does providing oxygen to a patient. The nurse would check for an as needed order for oxygen. Nurses must complete three checks, follow the sixrights of medication administration, and document appropriately when administering medications, but those actions are not the priority due to the change in the patient’s condition. The nurse must first address the patient’s shortness of breath.

Answer 97

a. Continuously reassess the patient. Rationale: After the nurse completes a patient’s initial assessment and develops a plan of care, continual reassessment of the patient detects noticeable changes in the patient’s condition, requiring adjustments to interventions outlined in the plan of care. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing essential care.

Answer 98

a. Gender diversity involving generational norms. Rationale: The nurse must perform the procedures competently and safely, taking into consideration any special needs of the patient. Gender diversity occurs with the identification of gender roles that may affect care delivery. Some patients may prefer care from nurses of the same gender. This preference may stem from generational norms, personal comfort, or cultural considerations. With life span diversity, interventions must always be age or developmental level appropriate. Disability diversity requires that interventions be individualized for each patient and adapted for any limitations. The nurse must ensure safe practice in relation to patient body size (morphology diversity) and should seek additional support or equipment when necessary.

Answer 99

d. Infuse 1 unit packed red blood cells. Rationale: Some interventions may be declined because of religious affiliation (e.g., blood transfusion for a Jehovah’s Witness, pork-based insulin for a Muslim patient).

Answer 100

d. The patient will report any purulent wound drainage to the primary care provider after discharge Rationale: Interventions must be individualized for each patient and adapted for any limitations (e.g., amputation, learning disability, blindness, deafness). The patient would be able to detect a foul odor, report pain, and remain injury-free, but would not be able to tell if drainage is purulent.

Answer 101

c. Providing emotional support Rationale: Independent nursing interventions are tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order. Repositioning a patient in bed, performing oral hygiene, and providing emotional support through active listening are examples of independent nursing interventions. Dependent nursing interventions are tasks the nurse undertakes that are within the nursing scope of practice but require the order of a primary care provider to be implemented. Administering patient medications or administering oxygen to a patient are examples of common dependent nursing interventions that require clinical judgment before implementation. These interventions are based on a collaborative effort of the nurse and the physician to provide care to patients.

Answer 102

b. Use of patient-controlled analgesia Rationale: Readiness to learn is an important consideration. For example, when a patient returns from surgery, it is essential that some information be reviewed (e.g., how to use the patient-controlled analgesia pump and incentive spirometer) but completing all discharge teaching at this time would not be effective. At other times, teaching is more formalized, such as discharge teaching, signs of infection, and physical therapy.

Answer 103

d. The patient who was recently diagnosed with diabetes mellitus and is scheduled to be discharged in 2 days Rationale: Choosing opportunities when the patient’s condition and environment are most conducive to learning is recommended when attempting to teach patients. Patients who are in pain, are nauseated, or who have been given recent traumatic diagnoses are not psychologically able to retain information.

Answer 104

a. Involving the family empowers the patients and their support system. Rationale: With the patient’s permission, the nurse should share instructions with the people who may assist with care. Nurses empower patients and their support systems through effective teaching. When nurses provide patients and their families with opportunities to ask questions and comprehend health care information, they become an integral part of the health care process. The family members may ask fewer questions but that is not a reason to involve them. Nothing will ensure patient compliance other that the patient deciding to do so. Family members may be interested in the information, but that is not the main reason to include them.

Answer 105

a. Indirect care Rationale: Indirect care includes nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients. Examples of indirect care include making the change-of-shift report, communicating and collaborating with members of the interdisciplinary health care team, and ensuring availability of needed equipment. Direct care refers to interventions that are carried out by having personal contact with patients. For example, direct-care interventions include cleaning an incision, administering an injection, ambulating with a patient, and completing patient teaching at the bedside. Referrals in health care involve sending a patient to another member of the interdisciplinary health care team for a consultation or other services. Delegation is the transfer of responsibility for performing a task to another person while the nurse who delegated the task remains accountable.

Answer 106

d. Dermatologist Rationale: A primary care provider (PCP) may refer a patient to a medical or surgical specialist for further assessment, testing, or treatment. Nurses are often instrumental in initiating these types of referrals but do not complete the actual referral. Referral to a community agency is usually a collaborative action. Obtaining adaptive services and music therapy are independent nursing actions.

Answer 107

d. Nurses must read recent literature and remain current in practice. Rationale: To implement research-based interventions, nurses must-read recent literature and remain current in practice. Implementation of evidence-based care is not unique to nursing; it involves interventions provided by all members of the interdisciplinary health care team. The best methods for treating patients with a variety of signs and symptoms are researched by nurses with input from the research findings of other disciplines. Nursing care continues to evolve as nursing research provides new knowledge and recognizes best practices to improve patient care and outcomes. Evidence-based practice guidelines and updated information must be included in plans of care.

Answer 108

a. Advocate Rationale: Nurses advocate by supporting and working on behalf of patients or persons for whom they have concern. Nurses advocate for patients by coordinating care and supporting the changes necessary to improve conditions and outcomes. Effective communication and collaboration regarding patient care are essential for patient safety and positive patient outcomes. The change-of-shift reports are an example. A PCP is usually a physician or advance practice nurse. Delegation is the transfer of responsibility for performing a task to another person while the nurse who delegated the task remains accountable.

Answer 109

b. Assessing lung sounds Rationale: Delegation is the transfer of responsibility for performing a task to another person while the nurse who delegated the task remains accountable. Obtaining vital signs, bathing, and ambulating are all tasks associated with the assessment part of the nursing process. The nursing process cannot be delegated.

Answer 110

b. Independent nursing interventions Rationale: Independent nursing interventions are tasks within the nurse’s scope of practice and do not require an order from a physician. Dependent nursing interventions are tasks the nurse undertakes that are within the nursing scope of practice but require the order of a primary care provider to be implemented. Some physician orders are received through a preapproved standardized order set known as standing orders. Counseling is the process through which individuals use professional guidance to address personal conflicts or emotional problems.

Answer 111

b. Dependent nursing intervention Rationale: Dependent nursing interventions are tasks that require an order from a physician or primary care provider (PCP). Independent nursing interventions are tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order. Referrals in health care involve sending a patient to another member of the interdisciplinary health care team for a consultation or other services. Indirect care includes nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients.

Answer 112

a. It should be completed accurately and in a timely manner. Rationale: All documentation entries should be completed in a timely, accurate, and professional manner. Documentation most often is charted in the patient’s EHR and standardized flow sheets according to agency policy. Patient health records are legal documents. Within the Health Insurance Portability and Accountability Act (HIPAA) guidelines, patient documentation is provided to insurance companies and others for billing and reimbursement.

Answer 113

d. The focus is patient responses to interventions and outcomes. Rationale: Evaluation is the final step in the nursing process. Evaluation focuses on the patient and the patient’s response to nursing interventions and outcome attainment. Evaluation is not a record of care that was implemented. Patient outcomes serve as the criteria against which the success of a nursing intervention is judged. During the evaluation phase, nurses use critical thinking to determine whether a patient’s short- and long-term goals were met and whether desired outcomes were achieved. Monitoring whether the patient’s goals were attained is collaborative, involving the patient in the decision-making process.

Answer 114

a. Revise or adapt the plan of care. Rationale: When a patient goal is unmet or only partially met, the plan of care may need to be revised or adapted to support goal attainment. There are many reasons why goals are not met, including changes in the patient condition, unrealistic goals, or inappropriate interventions that do not help meet the goal. It is common for plans of care to change to meet evolving needs. Reassessment occurs with each patient-nurse interaction. As changes in a patient’s condition occur, the plan of care should be revised.

Answer 115

b. Nursing process is dynamic and cyclic. Rationale: The nursing process is ongoing in an attempt to meet patient needs. The nursing process is not linear in nature but is dynamic and cyclic, constantly adapting to a patient’s health status. Care plan modifications may be necessitated due to deterioration or improvement of a patient’s condition. The Joint Commission requires patient care plans to be evaluated on a continual basis.

Answer 116

a. Immunization programs b. Cleansing an incision c. Cardiac risk factor modification d. Placing infants prone when they sleep e. Teaching patients to ask their providers to wash their hands Rationale: Some interventions prevent illness or complications and promote healthy activities or lifestyles. Interventions such as patient education and immunization programs are prevention-oriented. Cleansing an incision is a nursing intervention that can help prevent infection. Educating a patient about risk-factor modification for cardiovascular disease may prevent a future myocardial infarction. Placing infants on their backs to sleep may reduce the risk of sudden infant death syndrome. Patients should be instructed to ask their care providers to wash their hands if they have not observed them doing so.

Answer 117

b. Starting an intravenous (IV) line d. Inserting a urinary catheter Rationale: Many interventions focus on physical care that is performed when treating patients. These interventions may include invasive procedures, such as starting an intravenous line or inserting a catheter, or they may be noninvasive, such as administering oral medications and repositioning.

Answer 118

c. Right person d. Right supervision e. Right task Rationale: Delegation principles focus on the appropriate intervention (task) being performed under the correct circumstances, by the correct personnel, and with the correct direction and supervision. The right patient and the right time refer to components of the “6 Rights” of medication administration.

Answer 119

b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours Rationale: The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.

Answer 120

c. Portal of entry Rationale: Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.

Answer 121

c. Parasitic Rationale: Parasitic infections are frequently indicated on a CBC by elevated basophil and eosinophil levels. Bacterial infections do not lead to elevated basophil and eosinophil levels but elevated B and T lymphocytes, neutrophils, and monocytes. Fungal infections do not lead to elevated basophil and eosinophil levels. Viral infections create elevations in B and T lymphocytes, neutrophils, and monocytes.

Answer 122

c. “If I don’t feel sick, then I don’t have to worry about transmitted diseases.” Rationale: People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a pathogen. Travelers may need different vaccinations when traveling to countries outside their own because of variations in prevalent microorganisms. Food and water supplies in foreign countries can contain microorganisms that will affect a body unaccustomed to their presence. Adequate hygiene is essential when in crowded, public spaces like planes and other forms of public transportation.

Answer 123

d. The specific type of pathogen that is causing an infection. Rationale: People can transmit pathogens even if they don’t currently feel ill. Some carriers never experience the full symptoms of a pathogen. A CBC will identify that the patient has an infection. Inspection and radiography will help identify where an infection is located. The CBC with differential will identify the white blood cells being used by the body to fight infection. The culture will grow the microorganisms in the sample for identification of the specific type of pathogen.

Answer 124

b. Use of personal protective equipment c. Patient teaching on methods to inhibit transmission e. Administration of intravenous fluids f. Strict monitoring of intake and output Rationale: Protease inhibitors are used for treatment of viral infections, not bacterial infections. The nurse wants to protect visitors from exposure to the bacteria and protect the patient from secondary infection while immunocompromised, but the patient will need the support of family and close friends. Contact isolation precautions must be strictly followed along with the use of personal protective equipment and teaching on methods to inhibit transmission to help break the chain of infection. Intravenous fluids and strict intake and output monitoring will be important for the patient suffering the effects of Clostridium difficile, because it causes diarrhea with fluid loss.

Answer 125

a. Uninsured or underinsured status c. High cost of medications d. Inadequate nutrition Rationale: Individuals of low socioeconomic status tend to be part of the underinsured or uninsured population. Lack of insurance decreases accessibility to health care in general and health screening services specifically. High costs of medication and nutritious food also make this population at higher risk for infection. Gender has not been shown to be an increased risk factor for infection in the lower socioeconomic population.

Answer 126

b. Inflammatory response Rationale: The second line of defense is the inflammatory response. Inflammation is a local response to cellular injury or infection that includes capillary dilation and leukocyte infiltration. Normal flora is the body’s first line of defense. The immune response is the body’s attempt to protect itself from foreign and harmful substances. Humoral immunity is a defense system that involves white blood cells (B lymphocytes) that produce antibodies in response to antigens or pathogens circulating in the lymph and blood.

Answer 127

a. Humoral Rationale: Humoral immunity is a defense system that involves antibodies and white blood cells that are produced to fight antigens. Cellular immunity involves defense by white blood cells against any microorganisms that the body does not recognize as its own. The innate (nonspecific) immune system provides immediate defense against foreign antigens. Passive immunity occurs when a person receives an antibody produced in another body.

Answer 128

a. Pathogen Rationale: Infectious agents include any disease-causing agent and are called pathogens. They include bacteria, fungi, viruses, and parasites. Normal flora is a group of non–disease-causing microorganisms that live in or on the body. Germ is a term used for microorganism. A microorganism is bacteria, fungi, or protozoa.

Answer 129

d. Bacteria Rationale: Antibiotics are effective against bacteria, and exact antibiotic sensitivity is tested so that appropriate antibiotic are prescribed. Infections that are caused by fungi are treated with antifungal medications. Certain antiviral medications are used to manage the symptoms of a viral infection. These medications, if given during the early phases of illness, can decrease the amount of time that the patient has viral symptoms. Treatment for parasitic infections varies depending on the type of parasite.

Answer 130

d. Antifungal Rationale: The nurse would expect to treat athlete’s foot with an antifungal because it is a fungal infection. An antibiotic treats bacterial infections, antivirals treat viral infections and antihelminth treats parasitic worms.

Answer 131

d. Mode of transmission Rationale: The stethoscope would be a means for the pathogen to travel from source to host. The source is the reservoir or host. The portal of exit is where the pathogen escapes from the reservoir of infection, and the portal of entry is where the microorganism enters the susceptible host.

Answer 132

a. Vectors Rationale: Vectors carry pathogens from one host to another. Bacteria are single-cell organisms. Viruses are the smallest organisms. Fungi are single-cell organisms that can cause infection.

Answer 133

d. Handwashing Rationale: Handwashing is the most effective method to prevent hospital-acquired infections. Sterile technique is only used for certain procedures and isolation protocols are used for patients already infected or for protective isolation in immune-compromised patients and are not used for every patient. Antibiotics are used to treat infections.

Answer 134

a. An 80-year-old male with an enlarged prostate Rationale: The 80-year-old male has more risk factors because he is elderly and has increased risk of urinary tract infection related to prostate enlargement, so he has two risk factors. A 24-year-old female runner is likely healthy with no additional risk factors. The 50-year-old obese male has one additional risk factor. The 40-year-old sexually active female may not have additional risk factors if she is using protection and does not have multiple partners.

Answer 135

c. Patient’s incision will be without signs or symptoms of infection at discharge. Rationale: Maintaining skin integrity is an appropriate goal for this patient to ensure the patient does not develop a wound infection. Ambulating will assist in preventing skin breakdown be getting the patient out of bed, but it is not the priority goal for a patient with an incision. Consuming only 20% of meals will not ensure adequate nutrition and verbalizing the end of antibiotic administration to be when symptoms end is inappropriate. Antibiotics should be taken until the prescription is complete.

Answer 136

b. Patient with Clostridium difficile Rationale: Soap and water must be used to thoroughly clean hands if there is any visible soiling or dirt and with certain infections such as Clostridium difficile and vancomycin-resistant enterococci when preparing for a sterile or surgical procedure, before and after eating, and after using the restroom. In the other situations, a hand sanitizer is as effective as soap and water.

Answer 137

d. Eyewear, mask, gown, and gloves Rationale: Use gloves routinely when blood or body fluid might be present. If splashing is possible, use your nursing judgment about what other PPE might be necessary. Forceful expulsion of secretions would require all PPE—gown, mask, eyewear, and gloves—to provide adequate protection.

Answer 138

b. Contact Rationale: Contact precautions are used when a known or suspected contagious disease may be present and is transmitted through direct contact with the patient or indirect contact with items in the patient’s environment. Airborne precautions are used when known or suspected contagious diseases can be transmitted by means of small droplets or particles that can remain suspended in the air for prolonged periods. Droplet precautions are used when known or suspected contagious diseases can be transmitted through large droplets suspended in the air. Protective isolation is used for patients who have compromised immune systems.

Answer 139

a. Droplet Rationale: Droplet precautions are used when known or suspected contagious diseases can be transmitted through large droplets suspended in the air. Contact precautions are used when a known or suspected contagious disease may be present and is transmitted through direct contact with the patient or indirect contact with items in the patient’s environment. Airborne precautions are used when known or suspected contagious diseases can be transmitted by means of small droplets or particles that can remain suspended in the air for prolonged periods.

Answer 140

a. Gloves, eyewear, gown, and mask Rationale: When removing PPE, gloves, which are contaminated, are removed first to prevent contamination of the face and eyes during removal of the mask and to prevent spread of microorganisms. Eyewear should then be removed, followed by the gown and finally the mask.

Answer 141

c. Place sterile gloved hands below waist. Rationale: Once the hands have been placed below the waist, they can longer be considered sterile or free from organisms. Asepsis refers to freedom from disease-causing contamination. All other choices maintain asepsis.

Answer 142

a. Decreased cough reflex b. Decreased lung elasticity d. Abnormal swallowing reflex Rationale: The elderly are at an increased risk for respiratory infections because of decreased cough reflex, decreased elastic recoil of the lungs, decreased activity of the cilia, and abnormal swallowing reflex. They do not generally have increased sputum production.

Answer 143

a. “I should take antibiotics every time I am sick.” c. “I should save all unused antibiotics.” d. “I should stop taking antibiotics when I feel better.” Rationale: The overuse of antibiotics and inappropriate use, such as not completing prescriptions and sharing antibiotics, has led to increased resistance. Taking antibiotics as prescribed helps to ensure the infection will be treated correctly. A rash may indicate an allergic reaction and the patient needs to report this to the provider.

Answer 144

a. Wash hands first, then wrists. b. Rinse from fingertips to wrists. c. Dry using a scrubbing motion. Rationale: When washing hands, first wet the wrists and hands; with fingers pointing downward, first wash the wrists and then the hands below the wrists. Then apply soap, lather, and rub using a circular motion for 15 to 20 seconds. When rinsing, rinse from wrist to fingertips, keeping hands with fingers pointing downward. Using clean paper towels, dry thoroughly in the same order (from wrists to fingers) using a patting motion. Turn off the faucet with a clean, dry paper towel.

Answer 145

a. All patients e. Patients who are bleeding Rationale: The nurse can take steps at any link in the chain to halt the spread of infection. Standard precautions are used with all patients to limit direct exposure to blood and body fluids. The other choices are additional precautions such as airborne precautions are used with patients who have diseases such as tuberculosis and contact precautions with patients who have MRSA.

Answer 146

c. No live plants are allowed in the room. e. Everyone entering the room wears a mask. Rationale: Protective precautions may require a positive-pressure room. No live plants, fresh flowers, fresh raw fruit or vegetables, sushi, or blue cheese may be brought into the room because they may harbor bacteria and fungi. The patient cannot eat just any foods because some are restricted. A mask is required for anyone entering the room and for the patient if leaving the room.

Answer 147

C. Every 4 hours Rationale: Oral care should be performed every 4 hours to prevent the colonization of bacteria. Less often than every 4 hours is not effective.

Answer 148

A. NG tube insertion Rationale: NG tube insertion requires a clean, not sterile, technique as the gastrointestinal tract is not sterile. Use strict aseptic technique when inserting an intravenous (IV) or Foley catheter and when performing suctioning of the lower airway.

Answer 149

a. Prepare to administer vancomycin.

Answer 150

a. Ensure that the radiology department is aware of the Isolation Precautions.

NSG 100 Exam 1 Flashcards

(174 cards)