wrong Flashcards
(42 cards)
The nurse is beginning the interview of a patient who complains of a backache. What is an appropriate first question for the nurse to ask?
- “Who helps you at home?”
- “Are you having pain now?”
- “What brings you to the hospital today?”
- “On a scale of 0 to 10, how would you rate your pain?”
“What brings you to the hospital today?”
- Open-ended questions should be used when beginning an assessment as such inquiries allow patients to express their problems in greater detail. Therefore, the nurse should ask the patient about the reason for the hospital visit. Questions about help at home, current pain, or the estimate of pain are closed-ended questions and should be avoided at the beginning of the interview.
The nurse is caring for a patient with a pressure ulcer on his left hip. The nurse asks the patient several questions to determine how he may have gotten the pressure ulcer. Which of Gordon’s model of 11 functional health patterns should the nurse address in her assessment? Select all that apply.
- Sleep-rest
- Elimination
- Pain and weakness
- Nutritional-metabolic
- Past medical history or family history
-Sleep-rest
-Elimination
-Nutritional-metabolic
Gordon’s model of 11 functional health patterns includes health perception and health management, nutritional-metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception and self-concept, role-relationship, sexuality-reproductive, coping and stress-tolerance, and value-belief.
The past medical or family histories and pain or weakness are not among Gordon’s models of 11 functional health patterns.
A patient has arrived at the emergency department (ED) complaining of fatigue and memory loss. While performing the health assessment, which back-channeling techniques may the nurse use during the patient interview? Select all that apply.
- “I see.”
- “Go on.”
- “All right.”
- “Where does it hurt?”
- “When did the complaint start?”
- Maintain good eye contact and show interest in what the patient is saying
- “I see.”
- “Go on.”
- “All right.”
- Maintain good eye contact and show interest in what the patient is saying
- Back-channeling techniques such as stating, “Go on,” “I see,” and “All right” reinforce the nurse’s interest in what the patient has to say and encourage the patient to provide more details. Maintaining good eye contact and showing interest are also important back-channeling techniques. The questions, “Where does it hurt?” and “When did the complaint start?” are examples of open-ended questions, not back-channeling techniques.
The nurse is caring for a 50-year-old patient. The patient had his gall bladder removed, and it is the second postoperative day. The nurse finds that the patient is uncomfortable and is in pain. The nurse also notices some oozing from the site of surgery and decides to gather information from the patient about the pain. Which questions related to the complaint could the nurse ask? Select all that apply.
- “Have you passed stools normally today?”
- “Can you show me where exactly the pain is?”
- “What did you have for dinner last night?”
- “Have you turned or moved since last night?”
- “On a scale of 0 to 10, how severe would you rate this pain?”
- “Can you show me where exactly the pain is?”
- “Have you turned or moved since last night?”
- “On a scale of 0 to 10, how severe would you rate this pain?”
- The nurse has to inquire about the pain that the patient is experiencing. Asking where exactly the pain is gives the location of the pain. Asking if the patient has turned or moved helps the nurse to establish mobility status as well as severity of pain. Asking the patient to rate the pain on a scale of 0 to 10 helps to assess the severity of pain. Asking if the patient has passed stools does not help in assessing the pain nor does inquiring about the prior evening’s dinner.
The nurse is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths per minute. He lost his wife just a month ago. The nurse’s knowledge about this patient would result in which type of assessment approach at this time? Select all that apply.
- A problem-focused approach
- A structured, comprehensive approach
- Using multiple visits to gather a complete database
- Focusing on the functional health pattern of role-relationship
- Scheduling a single, extensive, structured interview to gather a detailed assessment
- A problem-focused approach
- Using multiple visits to gather a complete database
- The nurse should use a focused approach initially to determine the patient’s respiratory status. However, to gather an admission assessment, multiple visits are necessary because of the patient’s age and level of physical distress. A structured, comprehensive approach is not appropriate for this acute situation. Eventually the nurse will want to assess the patient’s role-relationship health pattern because of his wife’s death. However, it is not appropriate at this time.
Which are examples of data validation? Select all that apply.
- The nurse assesses the patient’s heart rate and compares the value with the last value entered in the medical record.
- The nurse asks the patient if he is having pain and then asks the patient to rate the severity.
- The nurse observes a patient reading a teaching booklet and asks the patient if she has questions about its content.
- The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement.
- The nurse asks the patient to describe a symptom by saying, “Go on.”
- The nurse assesses the patient’s heart rate and compares the value with the last value entered in the medical record.
- The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement.
-Validation involves comparing data with another source. Collecting pain assessment information, asking an open-ended question about a patient’s understanding of a booklet, and using active listening prompts such as “go on” when asking a patient to describe a symptom are not techniques that validate data.
The nursing diagnosis Impaired Parenting related to mother’s developmental delay is an example of a(n):
Risk nursing diagnosis. Incorrect
Problem-focused nursing diagnosis. Correct
Health promotion nursing diagnosis.
Wellness nursing diagnosis.
Problem-focused nursing diagnosis.
This is an example of a problem-focused nursing diagnosis with a related factor, based on NANDA-I diagnostic terminology. Most health promotion diagnoses do not have established related factors based on NANDA-I; their use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses.
A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: Collaborative data set. Diagnostic label. Related factors. Data cluster.
Data cluster
A data cluster is a set of cues (i.e., the signs or symptoms gathered during assessment).
A nurse is reviewing a patient’s list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement?
Identifying the clinical sign instead of an etiology
Identifying a diagnosis on the basis of prejudicial judgment
Identifying the diagnostic study rather than a problem caused by the diagnostic study
Identifying the medical diagnosis instead of the patient’s response to the diagnosis.
Identifying the medical diagnosis instead of the patient’s response to the diagnosis.
Intestinal colitis is a medical diagnosis. The related factor in a nursing diagnostic statement is always within the domain of nursing practice and a condition that responds to nursing interventions. Nursing interventions do not change a medical diagnosis.
A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. What are the steps for making a nursing diagnosis in the correct order, beginning with the first step?
- Considers context of patient’s health problem and selects a related factor
- Reviews assessment data, noting objective and subjective clinical information
- Clusters clinical cues that form a pattern
- Chooses diagnostic label
2, 3, 4, 1
A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse’s assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient’s nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best “related to” factor?
Infant crying at breast
Infant unable to latch on to breast correctly
Mother’s deficient knowledge
Lack of infant weight gain
Mother’s deficient knowledge
In this scenario the related factor is the mother’s deficient knowledge. A related factor is a condition, historical factor, or etiology that gives a context for the defining characteristics, in this case the infant crying, inability to latch on to breast, and absent weight gain.
Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
Impaired Skin Integrity related to physical immobility Correct
Fatigue related to heart disease
Nausea related to gastric distention Correct
Need for improved Oral Mucosa Integrity related to inflamed mucosa
Risk for Infection related to surgery
Nausea related to gastric distention Correct
-The related factors in diagnoses “Fatigue related to heart disease” and “Need for improved oral mucosa integrity related to inflamed mucosa” are incorrect. The related factor of a medical diagnosis (in Fatigue related to heart disease) cannot be corrected through nursing intervention. In “Need for improved oral mucosa integrity related to inflamed mucosa” there is no diagnosis, but instead a goal of care. “Risk for infection related to surgery” is incorrect; risk nursing diagnoses do not have defining characteristics or related factors because they have not occurred yet.
A nurse reviews data gathered regarding a patient’s ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.)
Data collection. Correct
Data clustering.
Data interpretation. Correct
Making a diagnostic statement. Incorrect
Goal setting.
Data collection.
Data interpretation.
This is an example of an error in interpretation and data collection. When making a diagnosis, the nurse must interpret data that he or she has collected by identifying and organizing relevant assessment patterns to support the presence of patient problems. In the case of the two diagnoses in this question, there can be conflicting cues. The nurse must obtain more information and recognize the cues that point to the correct diagnosis.
In which of the following examples are nurses making diagnostic errors? (Select all that apply.)
The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data Correct
The nurse who measures joint range of motion after the patient reports pain in the left elbow
The nurse who considers conflicting cues in deciding which diagnostic label to choose
The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping
The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.
- The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data
- The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping
- The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.
When the nurse observes the patient wincing and holding his left side but does not gather additional assessment data, he or she makes a data collection error by omitting important data (i.e., pain severity). A nursing diagnosis cannot be made on basis of a single defining characteristic, as seen when the nurse identifies a diagnosis on the basis of a patient reporting difficulty sleeping. A nursing diagnosis needs to be related to a patient’s response, not a medical diagnosis such as pneumonia. The nurse who measures joint range of motion after the patient reports pain is correctly validating findings. Considering conflicting clues ensures that the nurse does not make an interpretation error.
The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply.)
Defines a patient’s problem, giving members of the health care team a common language for understanding the patient’s needs
Allows physicians and allied health staff to communicate with nurses how they provide care among themselves
Helps nurses focus on the scope of nursing practice
Creates practice guidelines for collaborative health care activities
Builds and expands nursing knowledge
- Defines a patient’s problem, giving members of the health care team a common language for understanding the patient’s needs
- Helps nurses focus on the scope of nursing practice
- Builds and expands nursing knowledge
The use of nursing diagnosis creates a common language for nurses to communicate patient care needs, allows nurses to focus on the realm and scope of nursing practice, and helps to develop nursing knowledge. It is not a language for physicians and allied health staff because they do not rely on providing nursing interventions. Terminology in nursing diagnosis may be familiar to other health care providers but not in a way for directing nursing interventions. Nursing diagnosis has the purpose of creating practice guidelines for nursing.
Which of the following nursing diagnoses is stated correctly? (Select all that apply.)
Fluid Volume Excess related to heart failure Incorrect
Sleep Deprivation related to sustained noisy environment
Impaired Bed Mobility related to postcardiac catheterization
Ineffective Protection related to inadequate nutrition
Diarrhea related to frequent, small, watery stools.
- Sleep Deprivation related to sustained noisy environment
- Ineffective Protection related to inadequate nutrition
The correct diagnoses of Sleep Deprivation and Ineffective Protection are worded with related factors that will respond to nursing interventions. Nursing interventions do not change a medical diagnosis or diagnostic test. Instead nurses direct nursing interventions at behaviors or conditions that they are able to treat or manage. The first two incorrect diagnoses use a medical diagnosis and diagnostic procedure respectively as related or etiological factors. These are not conditions that nursing interventions can treat. The last diagnosis is incorrect because it is related to an assessment finding of a symptom or a defining characteristic.
The nurse is teaching a group of nursing students about the application of a nursing diagnosis to nursing practice. Which statement made by a student indicates the need for further teaching?
“Nursing diagnosis helps with the identification of patient health problems.”
“Nursing diagnosis offers an approach to ensure comprehensive nursing assessment.”
“Research gives backing to nursing diagnoses that are used to identify a patient’s health care problem.”
“Nursing diagnosis improves the selection of nursing interventions by nurses in certain practice settings.”
The nursing diagnosis improves the selection of nursing interventions by nurses in all practice settings, not specific settings. The nursing diagnosis essentially helps the nurse identify patient health problems. Nursing diagnoses offer an approach to ensure comprehensive nursing assessment. Contributions from research build on the evidence for use of nursing diagnoses in identification of patients’ health care problems.
For a diagnosis of potential for pressure ulcers, what could be the possible related factors? Select all that apply. Age extremes Fluid retention Maturational crisis Impaired sensation
Age extremes Fluid retention Impaired sensation Physical immobilization Related factors are associated with a patient’s actual or potential response to the health problem and can be changed by specific nursing interventions. Age extremes, fluid retention, impaired sensation, and physical immobilization are related factors that produce a potential for pressure ulcers. Maturational crisis refers to a psychological imbalance in a person going through a transitional period. Maturational crisis is a factor related to anxiety. This would not cause changes in skin integrity.
In the given examples, which nurses are making nursing diagnostic errors? Select all that apply.
A nurse listens to lungs for the first time and is not sure if abnormal lung sounds are present.
After reviewing objective data, a nurse selects a diagnosis of fear before asking the patient to discuss her feelings.
A nurse uses an incorrect diagnostic label.
A nurse considers a patient’s cultural background when reviewing cues.
A nurse prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern.
- A nurse listens to lungs for the first time and is not sure if abnormal lung sounds are present.
- After reviewing objective data, a nurse selects a diagnosis of fear before asking the patient to discuss her feelings.
- A nurse uses an incorrect diagnostic label.
- A nurse prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern.
A nurse who listens to lungs for the first time and is not sure if abnormal lung sounds are present is displaying a lack of skill, an error in collecting data. After reviewing objective data, a nurse who selects a diagnosis of fear before asking the patient to discuss her feelings is using an insufficient number of cues, which is an error in interpretation. A nurse who uses an incorrect diagnostic label is not accurately identifying the problem, which is a labeling error. A nurse who prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern is an example of incorrect clustering, a clustering error.
The nurse is teaching a group of nursing students about the use of standard formal nursing diagnostic statements from the North American Nursing Diagnosis Association-International (NANDA-I). Which statements by a student indicate the need for further learning? Select all that apply.
“The nursing diagnostic statements foster the development of nursing knowledge.”
“The nursing diagnostic statements emphasize following traditional practice guidelines.”
“The nursing diagnostic statements align the role of the nurses with other health care providers.”
“The nursing diagnostic statements help the nurses focus on the scope of medical practice as a whole.”
“The nursing diagnostic statements allow nurses to communicate among themselves in both written and electronic formats.”
- “The nursing diagnostic statements emphasize following traditional practice guidelines.”
- “The nursing diagnostic statements align the role of the nurses with other health care providers.”
- “The nursing diagnostic statements help the nurses focus on the scope of medical practice as a whole.”
The standard formal nursing diagnostic statements of the North American Nursing Diagnosis Association-International (NANDA-I) promotes the creation of practice guidelines that reflect the essence and science of nursing. They do not necessarily follow the traditional guidelines, which have been handed over through generations. The nursing diagnostic statements do not align the role of the nurse with other health care providers; rather, it distinguishes the nurse’s role from that of other health care providers. Nursing diagnostic statements help nurses focus on the scope of nursing practice specifically, not medical practice as a whole. The nursing diagnostic statement essentially helps to foster the development of nursing knowledge. The nursing diagnostic statement allows nurses to communicate with each other in both written and electronic formats.
As per Yura and Walsh, what are the components of the nursing process? Select all that apply. Planning Evaluation Assessment Implementation Nursing diagnosis
Planning
Evaluation
Assessment
Implementation
As per Yura and Walsh, there are four components to the nursing process. They are assessment, planning, implementation, and evaluation. Nursing diagnosis is a part of the nursing process according to most other theorists, but Yura and Walsh do not consider it part of the nursing process.
The nurse is caring for a football player scheduled for ankle surgery. The patient communicates properly during the interview. The nurse finds a quiver in the patient’s voice as he expresses his worry about not being able to play. The nurse observes that the patient has fidgety hands and legs. The nurse concludes that the patient is uncertain about his ability to play postsurgery. What interventions should the nurse implement to reduce anxiety in the patient? Select all that apply.
- Explain the recovery process to the patient.
- Provide detailed instructions about the surgery.
- Consult with a psychologist regarding the patient’s behavior.
- Teach postoperative care to the patient and his caregiver.
- Encourage health-promotion activities such as exercise and routine social activities.
- Explain the recovery process to the patient.
- Provide detailed instructions about the surgery.
-Teach postoperative care to the patient and his caregiver.
Explaining the recovery process and the surgery may reduce the patient’s uncertainties regarding the recovery. Teaching postoperative care to the patient and caregiver makes him more self-reliant and may speed his recovery. The patient’s anxiety is not pathological; therefore, consulting with a psychologist at this stage is not advisable. Health-promotion activities should be encouraged postoperatively.
A patient complains of pain when swallowing solid food. The nurse asks the patient if he or she has a history of substance abuse that has caused this pain. What kind of diagnostic error is does the nurse make in this scenario?
Errors in data collection
Errors in data clustering
Errors in the diagnostic statement
Errors in interpretation and analysis of data
Errors in data collection
The nurse is gathering the wrong information when asking the patient about substance abuse and correlating it with pain when swallowing solid food. Errors in data clustering occur when the nurse clusters prematurely, incorrectly or not at all. Errors in the diagnostic statement occur when the etiology portion of the diagnostic statement goes the nurse’s scope of practice. The inability of the nurse to validate data may lead to a mismatch between clinical cues and the nursing diagnosis. This inability to validate leads to errors in interpretation and analysis of data.
The nurse suspects the exit of an infectious organism through a purulent skin discharge. What would be the components of this discharge? Serum Platelets Red blood cells White blood cells
White blood cells
A break in the integrity of the skin and mucous membranes may allow pathogens to exit the body, which may be exhibited by the presence of a purulent drainage. This purulent discharge contains white blood cells and bacteria. Serous exudates may contain serum. Platelets may not be present in any exudates. Sanguineous exudates may contain red blood cells.
