Term
| A hospital client who requires assistance with hygiene has expressed a preference for receiving a bed bath after lunch rather than in the morning. The nurse has consequently changed the nursing care plan. The nurse's action reflects which QSEN competency? |
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Definition
client-centered care
Adjusting a client's care in response to the client's preferences or abilities is indicative of client-centered care. Quality improvement is focused more broadly on systems and processes. Empathic care and accountability and adaptability are not QSEN competencies. |
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Term
| A nurse has recommended a regimen of over-the-counter medications for a client who has seasonal allergies. A colleague contends that the nurse has exceeded the scope of nursing practice by recommending medications to a client. To resolve this difference of opinion, the nurses should consult resources from what organization? |
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Definition
American Nurses Association
While each of the listed organizations provides resources and information of different types, this dispute is directly related to scope of practice, which is delineated by the American Nurses Association's Nursing: Scope and Standards of Practice. |
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Term
| A group of student nurses has been encouraged by their instructors to be intentional and deliberate about applying clinical decision-making models to their practice. A student tells a colleague, "The model that makes the most sense to me is the information-processing model, because it seems the most straightforward." How should the colleague best respond to this student? |
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Definition
"It is definitely a clear model, but it does not really capture all of the complexities and the human element of nursing."
The information-processing model is attractive by virtue of its simplicity and linear nature. However, there is no significant drive to apply this model to nursing practice, because nursing is psychosocially complex and cannot be reduced to a simple equation of input and output. For this reason, it has never been predominant in nursing, even in past decades. It has not been proven to achieve better client outcomes in the literature. |
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Term
| A novice nurse has entered a two-bed hospital room to discover a client acting out physically and another client reporting a new onset of chest pain. In addition, the overhead P.A. system is reporting a code blue in a nearby room. These rapid and numerous changes are likely to immediately challenge the nurse's: |
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Definition
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Term
| A student nurse who is soon to graduate is completing a preceptorship with a nurse who has many years of clinical experience. The student has marveled at the nurse's ability to derive meaning from complex and rapidly changing situations, relying heavily on nurse intuition. What characteristic of this nurse does this ability demonstrate most clearly? |
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Definition
The nurse is an expert, according to Benner's novice-to-expert model of development.
Intuition is a marker of an "expert" in Benner's model. Rest's framework (which contains moral sensitivity and moral judgment) focuses on ethics rather than information-processing and meaning-making. Expert nurses do not practice beyond their legally defined scope. |
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Term
| In which situation(s) has the nurse applied deductive reasoning? Select all that apply. |
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Definition
The nurse applies the principle of homeostasis to understand a client's illness.
The nurse learns about the principles of transcultural nursing and uses these to choose interventions.
The nurse applies the theory of Human Thriving when working with clients who have disabilities.
The nurse uses Piaget's stages theory of human development when working with infants and children. |
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Term
| A novice nurse has been growing in skill, largely as a result of experiential learning in the clinical setting. Within the model of experiential learning, what outcome would most clearly indicate that the nurse has achieved the stage of transformation? |
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Definition
The nurse integrates experience and reflections into new forms of practice.
Transformation encompasses meaningful change that results from integrating new experiences with reflections. This may result in practice improvements, increased awareness of ethics, or influence on others, but it is the convergence of experience and reflection that most clearly indicates personal transformation. |
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Term
| A student nurse has been challenged to apply the principles of critical thinking during laboratory simulations. What characteristic of the student nurse's actions suggests that the student nurse engaged in critical thinking? |
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Definition
The student nurse thought systematically and reflectively before deciding what to do.
Although there are many definitions of what constitutes critical thinking, there is broad agreement that the process involves intentional, reflective thinking to inform an action. This approach does not presume that one will likely be wrong. It often leads to an examination of various options, but it is not realistic to identify every possible option. Critical thinking is not synonymous with criticizing others. |
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Term
| A nurse is applying Tanner's clinical judgment model in the care of a postpartum client. Which action by the nurse will constitute the first step in this process? |
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Definition
noticing the significant aspects of the client's condition
Tanner's iterative model begins with noticing; this takes place on the basis of the nurse's initial grasp of the situation and precedes hypothesizing. Reflection takes place during and after interactions but after the initial step of noticing. Trust and rapport are key aspects of care but do not represent the initial stage of Tanner's model. |
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Term
| The nurse is participating in a client conference for a client who has complex health needs. The client's psychiatrist, occupational therapist, and social worker are also participating in the conference. The nurse is most clearly demonstrating the values of what organization? |
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Definition
Interprofessional Education Collaborative
Active collaboration between health professions is the cornerstone of the Interprofessional Education Collaborative (IPEC) competencies. The actions are wholly consistent with the values of the other listed organizations, but the interdisciplinary nature of this action is a direct and practical example of IPEC competencies. |
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Term
| A nurse on a busy intensive care unit has developed a high level of situational awareness (SA) after several years of clinical experience. How will the nurse apply situational awareness to practice? |
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Definition
intervening or notifying another member of the team to intervene
The most tangible benefit of situational awareness (SA) in nursing is being able to provide interventions (or elicit them from others) in a response to client signs and symptoms, which may often be subtle and difficult to discern. Being able to shut out distractors can help develop SA, but this is not the most direct clinical manifestation of SA. Situational awareness may occasionally be helpful in developing rapport, but this is secondary to providing timely and appropriate interventions. Moral character is neither directly dependent on, nor does it result from, SA. |
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Term
| For which scenario will the nurse consult resources from the American Nurses Association? |
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Definition
The nurse is unsure whether a particular intervention is in the nursing scope of practice.
The American Nurses Association (ANA) produces Nursing: Scope and Standards of Practice. The National Council of State Boards of Nursing (NCSBN) administers the NCLEX. Quality and Safety Education in Nursing (QSEN) competencies are not within the purview of the ANA. Various organizations provide information and guidance on working with students, but this is not specific to the ANA. |
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Term
| A nurse is distraught that she failed to intervene promptly in a situation where a client's status declined sharply. The client was becoming agitated and aggressive. The nurse states, "There was just too much going on, all at once, and I basically froze and then panicked." What interpretation of this event is most accurate? |
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Definition
The speed and complexity of the situation overwhelmed the nurse's cognitive load.
Overstimulation in this case overwhelmed the nurse's cognitive load, leading to a failure to recognize, process, and act upon information. This is unrelated to the differences between inductive and deductive reasoning. The nurse's situational awareness decreased once overwhelmed, not increased. It is unlikely that this nurse's response was related to a lack of understanding that clinical judgment and clinical reasoning are important. |
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Term
| The nurse is describing a clinical encounter, stating, "I entered the room, gathered assessment data, and then provided the interventions specified in standard operating procedures." The nurse is applying which conceptualization of clinical decision-making? |
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Definition
information-processing model
The rote, linear approach to addressing issues that disregard client complexities is the information-processing model. Each of the other listed models integrates the complex, human realities of nursing practice. |
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Term
| A skilled nurse is providing care for a client with mental health needs who is recovering from a stroke. The client is experiencing dysphagia (difficulty swallowing), so the nurse is working together with the speech-language pathologist (SLP) to ensure the client's cooperation with a swallowing assessment. This nurse's action best demonstrates: |
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Definition
Interprofessional Education Collaborative (IPEC) core competencies.
Interprofessional Education Collaborative (IPEC) core competencies emphasize the need for interdisciplinary teamwork and collaboration, as demonstrated by working directly with a member of another health discipline. Reflection-in-action is a form of introspection and analysis within Tanner's model of clinical judgment, but there is no obvious indication that the nurse is doing this. The nurse's action is consistent with Rest's framework but this framework focuses on moral action, which is not described in the scenario. The nurse's action is well within the ANA Scope of Practice, but the focus on collaboration and teamwork is a more clear and apparent function. |
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Term
| A nursing student is excited to begin the first semester of the program and has learned that the competencies embedded in the program include human flourishing, nursing judgment, professional identity, and spirit of inquiry. What is the source of these competencies? |
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Definition
National League for Nursing
The competencies identified by the National League for Nursing include human flourishing, nursing judgment, professional identity, and spirit of inquiry. None of the other listed organizations share this particular taxonomy of competencies. |
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Term
| A community health nurse has a reputation that is described as "stellar" by peers and colleagues. Apart from the nurse's years of experience, the nurse's skillfulness is the attribute most described by others. According to cognitive continuum theory (CCT), what characteristic of the nurse suggests that the nurse has achieved the highest level of competence? |
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Definition
The nurse is able to apply intuition to complex clinical scenarios.
Cognitive continuum theory (CCT) acknowledges and integrates both intuitive and analytical cognitive characteristics. These values supersede years of service, reputation, or willingness to take on difficult work. |
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Term
| An experienced nurse has received a new client and will apply the principles of inductive reasoning in the care-planning process. What action will the nurse perform first when applying this form of clinical reasoning? |
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Definition
Gather objective and subjective assessment data.
Inductive reasoning requires observing, then drawing conclusions. That is, the process begins with data (such as assessment findings) and then progresses to identification of patterns or explanations. Presupposing the client's challenges or diagnoses would be contrary to this linear process. Beginning with a principle or theory is consistent with deductive reasoning. |
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Term
| A nurse has entered a client's home and noticed the client's disheveled state and several fall risks in the home. The nurse has interpreted these data as indications of a need for increased home support for the client and responded by arranging for care. The nurse reflected on the client's response to this suggestion, as well as reflected on the course of this interaction after the fact. The nurse has most clearly exemplified what model? |
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Definition
Tanner's clinical judgment model
Although the nurse's actions are not inconsistent with any of the listed models, the integration of the specific steps of noticing, interpreting, responding, and reflecting demonstrates Tanner's clinical judgment model. |
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Term
| A nursing student observed a staff nurse change a client's IV dressing. During post-conference, the student remarked to a classmate, "The nurse did not even follow the process we learned in lab!" What is the classmate's most appropriate response? |
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Definition
"You should consider some of the factors that might have influenced the nurse's action."
It is important to consider contextual factors and the underlying principles when reflecting on differences between what the student nurse learns and what the student nurse observes in practice. This does not entail ignoring what is seen in the clinical setting, but rather reflecting on it. It is an unfair characterization of nurses that they become sloppy after becoming licensed. Finally, the means and method by which nursing care is provided are important; the end result is not the sole consideration. |
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Term
| What action by the nurse in a hospital setting best exemplifies the goals of the Interprofessional Education Collaborative (IPEC) core competencies? |
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Definition
coordinating with the physical therapist to amend a client's activity orders in the plan of care
Interprofessional Education Collaborative (IPEC) competencies go beyond carrying out orders from another profession, reporting to a member of another profession, or one-way learning from another profession. Active collaboration on client care, such as working together on activity orders, demonstrates the participatory nature of the competencies. |
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Term
| A nursing student is providing care on a subacute step-down unit. The nursing student has received feedback that they are excessively tied to the rigid, stepwise performance of clinical tasks and fail to notice and accommodate the many contextual factors in client interactions. The nursing student is at what stage of Benner's humanistic–intuitive model of clinical judgment? |
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Definition
novice
Reliance on rote procedures and unawareness of contextual factors are the hallmarks of a novice. Advanced beginners have started to move away from this concrete thinking and performing. Benner's model does not include categories of precompetent or orientee. |
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Term
| A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology? |
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Definition
Gastrointestinal upset from food poisoning
The etiology identifies the physiological, psychological, sociological, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. The problem is fluid volume deficit. Vomiting and poor skin turgor are defining characteristics. |
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Term
| The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's parent reports that the infant cries much of the night but sleeps better in the daytime. The parent reports that the child only breastfeeds about four times in a 24-hour period and that the parent does not seem to have much milk. Which nursing concern is the priority for this parent–infant dyad? |
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Definition
altered breastfeeding
The frequency of breastfeeding is the likely cause of the infant's inability to gain weight. Feeding should be priority for a 3-week-old infant. Although the infant demonstrates an altered sleep pattern and altered comfort, these are not as important as the infant's inability to gain weight. There is no evidence that the parent is at risk for altered parenting. |
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Term
| A client has just given birth to the client's first newborn. The client reports to the nurse not knowing very much about newborns because of limited exposure to them. Which is the priority nursing concern for the nurse to address prior to discharge of this client? |
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Definition
knowledge deficiency
The client has indicated knowing little about care of a newborn. Education would be an appropriate intervention for this client. The client does not express fear, stress overload, or unproductive coping. Although the birth of the newborn may result in an alteration in the client's family processes, the priority concern at this time is the client's lack of knowledge about care of a newborn. |
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Term
| The nurse is caring for a 14-year-old client who has just gave birth. The client reports living with an aunt and having no other family around. The birth was uncomplicated, and the newborn is healthy. Which is the primary nursing concern the nurse will identify for this client's care planning? |
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Definition
altered parenting risk
A 14-year-old parent with little family support is at risk for difficulties with the expanded role of parent. The client has not stated feeling loneliness or pain. The newborn's feedings are not discussed in the scenario. |
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Term
| Which scenario is an example of a time-lapse reassessment? |
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Definition
A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.
Correct response:
The four types of assessment a nurse may perform are initial, focused, time-lapse, and emergency. A time-lapse reassessment is performed to reevaluate any changes in the client's health from a previous assessment. It is used to monitor the status of an already identified problem for a client with whom the nurse is already familiar. In this question the only scenario that depicts these components is that of the client with mobility issues. The assessment of the client who is found down on the floor is an emergency assessment. The assessment of each client based on the client's specific diagnosis is a focused assessment. The baseline assessment of the new resident in the long-term care facility is an initial assessment. |
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Term
| A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? |
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Definition
Risk for Community Contamination related to possible environmental pollution
The nurse has identified a risk diagnosis because of the unknown health effects of the chemical plant on the community. Risk for Community Contamination would address the broad concerns of the nurse. Knowledge Deficit is not appropriate because it has too narrow a focus. Deficient Community Health is not a NANDA-I diagnosis and the etiology must deal with how the plant may possibly affect the community. Risk for Infection has a very narrow focus. The etiology of community contamination has not been proven. |
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Term
| An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver? |
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Definition
The nurse uses open-ended questions when working with a crying client.
Any nurse who wishes to be an effective caregiver must first learn how to be an effective communicator. Good communication skills enable nurses to get to know their clients and, ultimately, to diagnose and to meet their needs for nursing care. By asking open-ended questions the nurse can gain more information as to why the client is crying. Without understanding the “why” behind the crying the nurse cannot determine if the hospital chaplain might be needed. Providing privacy for the client can be thoughtful but not a way to learn more. |
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Term
| What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses? |
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Definition
NANDA-International (NANDA-I)
NANDA-International (NANDA-I) conferences are held every 2 years, and much progress continues to be made in defining, classifying, and describing nursing diagnoses. The National League for Nursing (NLN) is a national organization for faculty nurses and leaders in nurse education. It offers faculty development, networking opportunities, testing services, nursing research grants, and public policy initiatives to more than 40,000 individual and 1,200 education and associate members. The Canadian Nurses Association is the national professional association representing over 139,000 registered nurses in Canada. The Canadian Medical Association is a national, voluntary association of health care providers that advocates on behalf of its members and the public for access to high-quality health care and provides leadership and guidance to health care providers. |
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Term
| A client who recently became quadriplegic as the result of a motor vehicle accident is experiencing multiple physical and emotional problems. To guide the care planning for this client, what type of nursing diagnosis would be most appropriate for the nurse to select? |
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Definition
A syndrome nursing diagnosis
Because the client is experiencing multiple problems beyond the scope of a single nursing diagnosis, a syndrome diagnosis is indicated. A problem-focused diagnosis, which addresses only one problem, is not sufficient. The client has identified actual problems, so a possible or risk nursing diagnosis would be inappropriate. |
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Term
| The nurse has obtained a new client's nursing history. This will primarily allow the nurse to perform which of the following? |
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Definition
Identify actual and potential health problems
The purpose of the nursing health history is to identify the client's strengths and weaknesses; health risks, such as hereditary and environmental factors; and potential and existing health problems. This interview does not typically include physical assessment of a client. As part of the nursing assessment and overall nursing process, its purpose is not to influence time within the process. The health care provider's medical work-up provides the data to develop the medical diagnoses. |
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Term
| The nurse on the night shift is caring for a hospitalized client who reports being unable to sleep. The client states, "I just cannot sleep here. I miss my home. There are too many lights and it is too hot." Which nursing concern does the nurse identify? |
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Definition
altered sleep pattern
The client has problems sleeping due to the unfamiliar environment. Although hospitalized, the client does not report isolation, powerlessness, or chronic pain. |
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Term
| After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview? |
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Definition
"Is there anything else we should know in order to care for you better?"
A helpful strategy in the termination phase of an interview is to ask the client: "Is there anything else you would like us to know that will help us plan your care?" This gives the client an opportunity to add data the nurse did not think to include. Expectations and previous practices should be addressed during the working phase of an interview. |
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Term
| A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? |
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Definition
Bowel Incontinence
Bowel incontinence is a NANDA-I-approved nursing diagnosis under the domain of Elimination. Ulcerative colitis, irritable bowel syndrome, and small bowel obstruction are medical diagnoses. |
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Term
| A client rates their leg pain at 8/10 on a 10-point pain scale. What type of cue is the client's description of pain in the right leg? |
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Definition
Subjective
Cues may be signs (objective) or symptoms (subjective). Objective cues, called signs, are observable, perceptible, and measurable by someone other than the person experiencing them. Subjective cues, called symptoms, are only observable, perceptible, and measurable by the person experiencing them. The pain described by the client in this question is a subjective cue, as only the client is able to perceive it. Explanatory suggests that the client would offer an explanation or comparison to describe the pain in the right leg. Severe is an adjective that might be the equivalent of 8/10 on the pain scale as reported by the client. |
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Term
| A novice nurse is conscientious to integrate QSEN competencies into care. What area(s) will the nurse emphasize? Select all that apply. |
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Definition
safety
evidence-based practice
informatics
client-centered care
quality improvement |
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Term
| The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called: |
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Definition
actual or potential nursing diagnoses.
Nursing diagnoses are established based on actual or potential health problems that are identified by the nurse and can be independently addressed. Collaborative diagnoses are selected when the nurse needs to work with another member of the health care team to assist the client in resolving the health issue. Dependent nursing diagnoses require a specific written order from the primary health care provider for a nurse to address. Syndrome nursing diagnoses address a cluster of actual or risk diagnoses that are predicted to be present as a result of a certain event or situation. |
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Term
| During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to: |
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Definition
body systems.
The categorization of assessment findings according to systems (in this case, musculoskeletal, gastrointestinal, and respiratory) is characteristic of a body systems model for organizing data. Although systematic, this strategy tends to ignore spiritual and psychosocial considerations. Human needs are based on food, water, and shelter. Human response patterns involve the subjective awareness of information. The functional health patterns model is used to provide a more comprehensive nursing assessment of the client focusing on sleep, roles, exercise, relationships, etc. |
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Term
| A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing diagnosis would be most appropriate for the nurse to select? |
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Definition
Readiness for Enhanced Knowledge: Childhood Immunizations
The community group is asking for information to enhance their health care habits. A health promotion diagnosis of Readiness for Enhanced Knowledge is indicated. There is no evidence of ineffective health maintenance practices. There is no evidence that the clients lack immunizations. Risk for Complications might result from a lack of immunizations, but that is not the issue being addressed here. |
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Term
| The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply. |
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Definition
Client states, "I feel so sad all of the time."
Client states, "I am in pain."
Subjective data are statements by the client. Objective data are observations made by the nurse when gathering data such as vital signs and physical signs. |
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Term
| The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first? |
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Definition
inspection
When the nurse performs a physical assessment, four techniques: inspection, palpation, percussion, and auscultation will be used. In most cases the nurse will perform them in sequence. Because palpation and percussion can alter bowel sounds, the nurse will inspect, auscultate, percuss, then palpate an abdomen. |
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Term
| The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client? |
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Definition
Pain
Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be observed if the client did not respond in a timely manner. A client with low anxiety is relaxed and would answer the question with intention and thoughtfulness. A hungry client would be short-tempered and angry. |
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Term
| When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make? |
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Definition
The nurse should determine the client's normal bowel elimination pattern.
To validate the diagnosis, the nurse must determine what is normal for the client. Dietary habits may contribute to constipation, but the nurse must first confirm that the client is actually constipated. Likewise, bowel sounds might help explain the cause of constipation, but the nurse should first confirm that the client is constipated. There is no standard elimination pattern; it is highly individualized. |
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Term
| What should the nurse do prior to performing an initial assessment on a newly admitted client? |
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Definition
Review the records available on the client.
Records prepared by different members of the health care team provide information essential to comprehensive nursing care. The nurse should review records early when gathering data before the first contact with the client. This review helps to focus the nursing assessment and to confirm and amplify information obtained already. The other actions are not appropriate prior to performing an assessment. An assessment must be done whether it is convenient or not, for the appropriate care to be given. |
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Term
| A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select? |
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Definition
Knowledge Deficit: Medications related to new medical diagnosis
To most appropriately address the client's health problem, the nurse should educate the client about the new medications the health care provider has prescribed to treat the asthma. Ineffective Airway Clearance refers to the physiologic processes of asthma. There is no evidence of noncompliance. There is no indication that the client is having difficulty dealing with the diagnosis. |
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Term
| The nurse is aware that nursing diagnoses are: |
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Definition
within the nursing scope of practice to develop and client-focused.
Nursing diagnoses are within the nursing scope of practice to develop and are client-focused. They are developed collaboratively with the client, are based on assessment data, and can change from day to day as the client’s responses change. They are not do not depend on nor are they dictated by medical diagnoses, and they are not based on the input of the primary care provider. |
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Term
| Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed? |
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Definition
Risk for Skin Breakdown related to bed rest
A risk nursing diagnosis,is “a clinical judgment concerning the susceptibility of an individual. The client in this scenario is most at risk for skin breakdown related to prolonged confinement to bed; however, proactive and continued nursing interventions can reduce this risk. Ineffective Airway Clearance and Immobility are not risk nursing diagnoses but actually nursing diagnoses, as they describe problems that already exist. Potential for Pneumonia is not a properly worded risk nursing diagnosis; "Risk for" should be included rather than "Potential for." |
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Term
| The nurse has provided analgesia to a client who was reporting pain, and the nurse used the NCSBN Clinical Judgment Measurement Model (CJMM) to inform the process. What action by the nurse represents the final step in this model? |
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Definition
evaluating the client's pain 30 minutes after administering the analgesia
Evaluating outcomes is the final step in the CJMM. All of the actions listed are appropriate, but evaluation is the most direct indication of this sixth and final step. |
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Term
| The nurse watches a 43-year-old client walk into the room and notes the client is slightly limping on the left foot when walking. The nurse also notes the client has difficulty sitting in the chair and sits down carefully with the left leg slightly held forward. The client notes having had difficulty walking for the past year and it is getting worse. A previous ultrasound of the foot revealed a Morton neuroma. The client reports continued pain in the left foot when walking or standing for long periods of time. A physical examination reveals pain and tenderness on palpation of the upper left foot, skin is cool to touch with no redness noted, pedal pulse is 78 beats/min and regular. Which action by the nurse demonstrates the observation phase of an assessment? |
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Definition
Watching client walk into room
Observation is the first step of a physical examination. This is when the nurse watches the client to observe any subtle indications of a problem, watches body language to see how it corresponds to the verbal communication, and determines possible areas which will need a focused assessment as the initial assessment develops. Review of past records should occur before the physical assessment is conducted. Assessing the area for pain, temperature and pulse are methods used during palpation. |
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Term
| Which is the primary reason for a nurse collecting data continuously on a client? |
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Definition
The client's health status can change quickly.
Data about the client is collected continuously because the client's health status can change quickly. It is not done as busy work nor is it to make the client feel good. Reimbursement is related to having certain assessments done, but is not based on continuous assessments of the client's condition. |
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Term
| A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address? |
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Definition
PC: Decreased Cardiac Output related to cardiac tissue damage
All these collaborative problems may be indicated for a client with a recent myocardial infarction; however, priority must be given to life-threatening issues. Decreased cardiac output is the only life-threatening problem among the answer options, so it must be the priority. |
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Term
| The home health nurse is performing a home visit to a client who has been diagnosed with postpartum depression. How can the nurse best demonstrate the Quality and Safety Education for Nurses (QSEN) competency of safety during this home visit? |
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Definition
assessing the client's risk for suicidal ideation during the visit
Assessing for suicidality is a direct and tangible expression of safety. Each of the other listed actions is consistent with safety but in a less direct manner. Rapport-building and offering support are most closely aligned with client-centered care. Assessment is also related to safety but in a less direct manner than determining suicide risk. |
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Term
| The nurse has entered a client's hospital room and noticed that the client is grimacing and reporting bladder fullness despite the presence of an indwelling urinary catheter. The nurse has collected and interpreted assessment data and believes that the catheter is occluded. When applying Tanner's model of clinical judgment, what should the nurse do next? |
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Definition
Choose an intervention and then evaluate the effect of the intervention.
Having performed the steps of noticing and interpreting, the nurse may progress to responding with nursing actions/interventions. Analysis of cues has already taken place during the phase of interpreting. Clear communication with the client is important, but there is no need to describe each assessment datum to the client. Reflection in Tanner's model takes place during and after nursing encounters; the progression toward action does not need to pause for reflection. |
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Term
| A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? |
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Definition
Focused
The nurse is performing a focused assessment, which involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the client's health. An emergency assessment is performed to identify life-threatening problems. A time-lapse assessment compares a client's current status to baseline data obtained earlier. |
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Term
| The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is: |
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Definition
the initial comprehensive client assessment.
The initial comprehensive client assessment results in the baseline data that enables the nurse to make judgments, plan care, and refer clients to other health care workers if necessary. |
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Term
| A new graduate is working in a public health unit that is staffed by several experienced nurses. Which description demonstrates that the nurse has attained the status of "expert" according to Benner's novice-to-expert model of nurse development? |
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Definition
a nurse who can consistently apply intuition to complex nursing situations
Although all of the listed nurses may potentially have attained the level of expert, a hallmark of an expert nurse in Benner's model is the ability to discern subtle cues and apply intuition to complex situations. |
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Term
| The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this infant, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate? |
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Definition
Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement
The client's statement indicates that it is difficult for the client to reach a decision because of the client's moral beliefs. The client is not expressing hopelessness or demonstrating ineffective coping or complicated grieving. The client may be suffering from rape trauma syndrome, but the assessment data do not lead to that diagnosis. |
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Term
| A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make? |
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Definition
"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions."
The nurse identifies nursing diagnoses to serve as a framework for planning care for a client. Nursing diagnoses guide the nurse toward appropriate interventions. Insurance is not billed with nursing diagnoses. Nursing diagnoses do not validate the medical diagnosis. Nursing diagnoses are not used to determine the amount of nursing care required. |
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Term
| A nurse practitioner in private practice with a health care provider is providing care to a client with a history of domestic violence. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing? |
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Definition
Time-lapse
The four types of nursing assessment include complete, focused, time-lapse, and emergency. In time-lapse assessments, the nurse reassesses a client and condition that is already known to re-evaluate the client's status. In this case the nurse is revisiting the client's feelings and plans to change her life situation by leaving her abusive husband. In emergency assessments, the nurse assesses the client for life-threatening problems which are acutely present.. In focused assessments, the nurse focuses on assessing a specific problem that is already known to exist to further refine planning interventions. In complete (general or initial) assessments, the nurse does a thorough assessment of all aspects of a client's health status on the client's admission to a health care facility. |
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Term
| A nursing student is growing personally and professionally through the experiential learning activities that are embedded in the curriculum. Place the actions that the student should perform in experiential learning in the correct sequence. Use all options. |
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Definition
Study the theory that underlies wound care.
Perform a sterile dressing change, in simulation or in clinical.
Perform personal reflection on the technique of dressing changes.
Experience personal transformation in wound care practice technique. |
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Term
| The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action? |
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Definition
Notify the health care provider for additional orders.
The client's decreased level of consciousness could indicate that the client is developing an electrolyte imbalance. The change in the client's status requires notification of the health care provider. Medication orders are required to treat the electrolyte imbalance. Documenting the level of consciousness is appropriate, but not as the priority action. Another nurse is not necessary to check the nurse's assessment. Decreasing stimulation and allowing the client to rest with no further action may result in harm to the client. |
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Term
| A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis? |
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Definition
| The client states, "I am sure the doctors have misdiagnosed me." |
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Term
| Which nursing skill uses all five senses? |
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Definition
Observation
Observation is the conscious and deliberate use of the five senses (sight, smell, hearing, taste, and touch) to gather data. Documentation uses sight (seeing the client's chart) and touch (typing on a keyboard or writing with a pen). Listening involves just hearing what the client is saying. Caring need not involve any of the senses but is displaying kindness and concern for others. |
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Term
| Which group of terms best defines assessing in the nursing process? |
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Definition
Collection, validation, communication of client data
Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem-focused, time-lapsed, and emergency-based describe types of assessments. Assessments are nurse-focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are. |
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Term
| A new nursing student has been surprised to learn that reflective journaling is a component of the curriculum. The student states to a colleague, "We would be better off spending our time working on our skills than writing in a journal." What benefit(s) of reflective journaling should the colleague describe to this somewhat frustrated student? Select all that apply. |
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Definition
"It can help you better understand your progress toward your learning goals."
"Reflection through journaling can help you draw more learning out of your experiences."
"Journaling can bring to mind aspects of a clinical experience that escaped you in the moment."
Reflective journaling has numerous benefits, including determination of goals, deriving new meaning from experiences, and enhancing the understanding of clinical experiences, which often unfold at a rapid pace. It is not, however, specified as a component of scope of practice, nor is it necessarily "superior" to kinesthetic skills practice; reflection and hands-on practice are both necessary for learning. |
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Term
| A nursing student has been providing care for several clients in both community and hospital settings. For which client will the nurse use a concept map when planning and providing care? |
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Definition
community-dwelling client with complex physical and psychosocial needs
Although concept maps can inform care in a wide variety of circumstances, they are especially helpful when planning care for clients who have longstanding, complex needs. Concept maps have less utility in time-dependent circumstances like emergencies or in clients whose needs are more finite, such as clients needing specific teaching or a single immunization. |
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Term
| The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping? |
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Definition
Health promotion nursing diagnosis
Readiness for Enhanced Coping is an example of a health promotion nursing diagnosis. Two cues must be present for a valid health promotion nursing diagnosis: a desire for a higher level of wellness and an effective present status or function. An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. A risk nursing diagnosis is a clinical judgment that concludes that an individual, family, or community is more vulnerable to develop the problem than are others in the same or a similar situation. A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation. |
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Term
| During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis? |
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Definition
The parent states, "I cannot allow anyone else to help because they won't do it right."
The parent's statement of not allowing anyone to help because "they won't do it right" supports the nursing diagnosis of Caregiver Role Strain. The parent's statement indicates an inability to allow help, which will cause mental and physical strain. The other statements indicate a healthy ability to use coping mechanisms to deal with this difficult situation. |
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Term
| A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action? |
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Definition
Verbally report the finding immediately to the client's health care provider.
The nurse should report any abnormal assessment findings or changes in the client’s health status to the client’s health care provider or the charge nurse immediately for prompt and appropriate treatment of the health alterations. The unlicensed assistive personnel should not document the findings as this is the nurse's responsibility. The nurse should not just reassess the client's temperature in 2 hours and chart that data; immediate reporting of the data to the health care provider or charge nurse is necessary. |
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Term
| The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment? |
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Definition
Supplement the client's information by speaking with family or friends.
Family and friends can be an invaluable source of assessment data, especially in the care of clients who have cognitive deficits. It would be inappropriate to limit an assessment to solely objective data. Using previous medical records and breaking up the assessment are appropriate measures, but they do not supersede the importance of using family and friends as data sources. |
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Term
Which scenario is an example of a time-lapse reassessment?
Seeing a client down on the floor, the nurse assesses the client's airway, breathing, and circulation, calls for help, and begins a quick neurological exam.
A nurse just coming on shift performs a focused physical assessment on each client, based on the client's diagnosis.
A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.
A nurse in a long-term skilled nursing facility assesses a new resident's baseline health status. |
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Definition
A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.
The four types of assessment a nurse may perform are initial, focused, time-lapse, and emergency. A time-lapse reassessment is performed to reevaluate any changes in the client's health from a previous assessment. It is used to monitor the status of an already identified problem for a client with whom the nurse is already familiar. In this question the only scenario that depicts these components is that of the client with mobility issues. The assessment of the client who is found down on the floor is an emergency assessment. The assessment of each client based on the client's specific diagnosis is a focused assessment. The baseline assessment of the new resident in the long-term care facility is an initial assessment. |
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Term
| A nurse is conscientious in applying the Quality and Safety Education for Nurses (QSEN) competencies to the provision of clinical care. To enact the value of quality improvement, the nurse should perform what action? |
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Definition
Advocate for changes to shift handoff so that the process is more efficient.
Process improvements, such as changes to communications like handoff, are indicative of quality improvement. Rapport-building is primarily associated with client-centered care and informing the team about a threat to health (e.g., decelerations) demonstrates safety as well as teamwork and collaboration. Client teaching is consistent with all the QSEN competencies but primarily with client-centered care. |
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Term
| The community nurse has entered a client's home and noticed that the client is agitated and exhibits restless body language. The nurse has interpreted these behaviors as a sharp departure from the client's usual behavior and has discerned that the behavior is related to a recent family conflict. Within Tannner's model of clinical judgment, what will the nurse do next? |
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Definition
Respond by selecting the appropriate interventions.
The continuum of nursing actions within Tanner's model progress from noticing (perceiving the client's behavior), interpreting (making meaning of the behaviors), to responding. Responding is characterized by choosing appropriate actions. Reflection is central to the model, but passive monitoring would not be a sufficient response to the client's behavior, which warrants the nurse's input. |
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Term
| After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? |
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Definition
Actual
"Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual nursing diagnosis, because it describes a human response to a health problem that is being manifested. A health promotion nursing diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A possible nursing diagnosis is made when not enough evidence supports the presence of the problem, but the nurse concludes that it is highly probable and wants to collect more information. |
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Term
| Which statement is true regarding addressing a priority problem? |
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Definition
A priority problem requires a nursing intervention before another problem is addressed.
A priority problem requires a nursing intervention before another problem is addressed, but addressing priority problems does not entail skipping any interventions. The priority of problems can change as a client's condition changes. There are no predetermined times or intervals at which to identify priority problems. This is why critical thinking plays a central role in nursing. |
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Term
| A nurse is asking questions about a client's sexual history. Which is the best question for the nurse to ask to determine the client’s use of safer sexual practices? |
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Definition
“How do you protect yourself when having sex?”
An open-ended question is the best type to use to gather the most information. Asking how the client uses protection during sex will obtain information about safer sex practices. Asking how many sexual partners the client has had or if the client is in a committed relationship will not help to ascertain the information. Asking, “Do you use condoms” is a closed-ended, yes or no question that will not provide comprehensive information. |
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Term
| Which describes the best approach for the development of nursing diagnoses? |
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Definition
Develop nursing diagnoses from clusters of significant data.
Nursing diagnoses should always be derived from clusters of significant data, rather than from a single cue. Nursing diagnoses describe client problems that nurses can treat independently and do not require collaboration with other members of the health care team. Therefore, nurses can develop nursing diagnoses without collaborating with health care providers or other health care team members. |
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Term
| A nursing student has set the goal of becoming more skilled and confident in clinical judgment and clinical reasoning. What action(s) will the nurse perform to achieve the goal? Select all that apply. |
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Definition
Be continually aware of ethical issues and ethical responsibilities.
Perform personal reflection during and after new experiences.
Learn to trust intuition, when appropriate to the complexity of the situation.
Adopt a systematic framework for practicing and evaluating clinical judgment.
Reflect on mistakes as well as successes. |
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Term
| A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis? |
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Definition
Anxiety
Anxiety is an accurate diagnostic label, the name of the nursing diagnosis as listed in the taxonomy. It is also the only option related to the client's experience to the new experience of being hospitalized. Compromised is a descriptor; physical immobility is a risk factor; overdistension is a related factor. |
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Term
| A client is caring for the client's mother-in-law, who is an older adult who requires assistance with performing activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain? |
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Definition
“I just don't have time to take a shower.”
Any of these statements could be a clue to caregiver role strain when clustered with other evidence. However, the inability to care for oneself, such as not taking time for a shower, strongly indicates that this client is not coping well. |
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Term
| The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client? |
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Definition
Explain the nurse will need to touch the client during the assessment
Some people of Chinese descent are modest about having their bodies touched and may see touching as an invasion into their personal space. The nurse should explain what will be done as the assessment progresses and strive to help the client feel as comfortable as possible. However, asking if the client would like the door left closed or opened, is not a priority before starting the assessment. It would be inappropriate to discuss various goals before the assessment is complete. All the information is needed to determine which goals will be most appropriate for each client. It may also be inappropriate to only conduct a focused assessment at this time, depending on the situation and the client. If there are other issues, they should also be evaluated, so that appropriate nursing goals can be determined and the client can receive the best care possible. |
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Term
| After completing a client abdominal assessment, the nurse finds diminished bowel sounds. To determine what intervention is needed, which step would the nurse take first? |
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Definition
Review the client's recent food and fluid intake.
The first step in interpreting and analyzing the data involves identifying cues or significant data that raise a red flag. From there, the nurse would look for patterns or clusters of data that signify an actual or possible nursing problem. Preparing the client for laxative administration indicates the nurse has skipped some necessary steps in the nursing process. The nurse must first engage in a process of analysis and interpretation of data prior to formulating a hypothesis about a potential or actual problem. Providing teaching about constipation and encouraging the client to change food and fluid intake assumes the nurse has proceeded logically through each step of the nursing process to develop the conclusion that diminished bowel sounds are the result of constipation. Further data needs to be collected, analyzed and interpreted before the nurse can plan and carry out this intervention. |
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Term
| The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by the client refusing to look at the surgical site and stating, ”I’m ugly. My husband will no longer find me desirable.” What is the etiology identified in this nursing diagnosis? |
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Definition
Decreased ability to cope with surgical removal of right breast
The etiology identifies the factors that contribute to the unhealthy client response or problem. Disturbed Body Image is the problem, which identifies what is unhealthy about the client, indicating the need for change. The client’s statements and refusal to look at the surgical site are defining characteristics that validate the existence of the problem. |
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Term
| What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall? |
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Definition
Assess blood pressure with a large cuff.
When assessing an obese client, a larger blood pressure cuff will likely be needed to prevent false high readings. It is not in the nurse's scope of practice to determine when and if cholesterol levels and an electrocardiogram are ordered. Diet education may or may not be warranted depending on the cause of the obesity. |
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Term
| Which items reflect the assessment phase of the nursing process? Select all that apply. |
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Definition
The nurse asks the client, “How would you rate your pain?”
The client's abdomen is firm and distended with hypoactive bowel sounds.
The client states, “I rarely sleep more than 6 hours.”
Assessment data would include the client statement regarding sleep, the nurse’s question about a pain rating, and physical assessment data of the abdomen. Seeking input from the data in setting goals would occur during the outcome identification and planning phase. Assisting the client with coughing and deep breathing would occur during the implementation phase. |
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Term
| A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents’ negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client? |
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Definition
High Risk for Injury related to unsafe home environment
The nursing diagnosis “High Risk for Injury related to unsafe home environment” is appropriate because it contains the NANDA-I nursing diagnosis problem statement and the etiology of the problem. High Risk for Injury related to abusive parents is accusatory and may not be accurate. High Risk for Injury related to impaired home management does not accurately identify the etiology of the problem. Child Abuse is not a NANDA-I approved nursing diagnosis. |
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Term
| A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client? |
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Definition
A focused assessment of the specific problems identified
The priority assessment at this time is a focused assessment of the client’s primary concern. A focused assessment may be performed during the initial assessment if the client’s health problem is apparent. A full assessment of the urinary system may be appropriate but is not the priority. A detailed assessment of the client’s sexual history is not warranted, and although a thorough systems review is conducted, it is not the priority at this time. |
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Term
| A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? |
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Definition
Focused
The nurse is performing a focused assessment, which involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the client's health. An emergency assessment is performed to identify life-threatening problems. A time-lapse assessment compares a client's current status to baseline data obtained earlier. |
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Term
| An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client? |
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Definition
Time-lapsed assessment
A time-lapsed assessment is scheduled to compare a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time are scheduled for this type of check. An emergency assessment is conducted if the client is having an emergency such as chest pain or hemorrhaging from the hand. Focused assessment is performed on clients focusing on the system or systems involved in the client's problem. Developmental stage assessment is the process of mapping a child's performance compared with children of similar age. |
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Term
| When is the best time for a nurse to take a client's health history? |
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Definition
As soon as possible after a client presents for care
The nursing health history captures and records the uniqueness of the client and should be obtained as soon as possible after a client presents to the health care facility for care. If the nurse waits until the client is ready, this may occur too late and the problem may become more problematic. Twenty-four hours is also too long. Waiting until the client is discharged is inappropriate because important medical as well as psychological information may be missed or not communicated. |
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Term
| A nurse is interviewing an asthmatic client who has a high respiratory rate and at times has difficulty breathing. The client is restless and at current can only speak a few words before pausing to catch a breath. What appropriate nursing diagnosis should the nurse document? |
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Definition
altered verbal communication related to the breathing problem
The client has a high respiratory rate and difficulty breathing; the client therefore has trouble communicating. Altered verbal communication related to the breathing problem is the appropriate diagnosis. Although altered gas exchange may occur in an asthma attack, it does not relate to the current concern regarding the client's ability to communicate thus it is not the primary concern at this time. There is no evidence that the client is experiencing altered physical mobility due to the condition. Unable to speak due to ineffective airway clearance is not accurate, because the client is able to speak, although the speech is impaired. |
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Term
| The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is: |
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Definition
the initial comprehensive client assessment.
The initial comprehensive client assessment results in the baseline data that enables the nurse to make judgments, plan care, and refer clients to other health care workers if necessary. |
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Term
Which client situation most likely warrants a time-lapse nursing assessment?
An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.
A nurse is auscultating the lungs and measuring the oxygen saturation of a client who has pulmonary edema.
The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain.
A client is being admitted to a general medicine unit after spending several days in the intensive care unit. |
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Definition
An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.
A time-lapse assessment is often indicated in the care of a stable client whose current status is being compared to earlier baseline data. Shortness of breath and chest pain necessitate an emergency assessment, while a new admission to a unit or institution requires an initial assessment. Following up a known health problem most often requires a focused assessment. |
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Term
| A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem? |
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Definition
Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis
The client is expressing a lack of hope for the future, which makes "Hopelessness" an appropriate nursing diagnosis. There is no evidence that the client has a disturbed self-concept. There is no evidence that the client is not effectively caring for health. The client does not verbalize a desire to learn about treatment options. |
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Term
| Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure? |
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Definition
Reporting signs and symptoms related to the client's kidney failure
In producing a nursing diagnosis, a nurse creates accountability for detecting and reporting the signs and symptoms of a medical diagnosis. The nurse is not legally responsible for independently managing or coordinating the client's treatment. Choosing and performing interventions to resolve the condition is primarily within the purview of the health care provider. |
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Term
| A 45-year-old client has presented to the emergency department with a report of nausea and vomiting and severe pain just under the right rib cage. Which response(s) should the nurse prioritize? Select all that apply. |
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Definition
"How long have your eyes had the yellow tinge?"
"Can you tell me more about the nausea and vomiting?"
"I am going to apply some pressure to your abdomen to see just exactly where the pain is." |
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Term
| A nurse is interviewing a hospitalized client. Which nurse–client positioning facilitates an easy exchange of information? |
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Definition
If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.
If the client is in bed, the nurse sitting in a chair placed at a 45-degree angle to the bed ensures the nurse is sitting at eye-level with the client, which promotes communication. If the nurse is standing at the foot or at the side of the client's bed, an authoritative position is established, which does not promote good communication. If both the nurse and the client are seated, being 30 cm apart intrudes upon personal space; ideally the nurse and client should be about 1 m apart. |
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Term
| The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side." This statement is an example of: |
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Definition
a cue.
Cues and inferences describe the early analysis of data. "The client does not respond when I speak while standing on the client's right side," is a cue that something may be wrong. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. A nurse can observe a cue directly but not an inference. The information in this case is based on the nurse's direct observation, not interpretation or inference, and thus cannot be a misinterpretation. There is no evidence that the nurse's observation duplicates other data collected. |
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Term
| A nurse documents the following in the client chart: Risk for Decreased Cardiac Output related to myocardial ischemia. This is an example of what aspect of client care? |
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Definition
Nursing diagnosis
The nursing diagnosis statement is worded by stating the client problem (using NANDA-I approved diagnoses) that the nurse is able to treat followed by the etiology of the problem. Nursing assessment refers to the collection of data. A medical diagnosis identifies diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Nurses cannot treat medical diagnoses independently. Collaborative problems are the primary responsibility of nurses. Unlike nursing diagnoses, with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines. |
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Term
| The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing? |
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Definition
functional assessment
The nurse is performing a functional assessment that focuses on areas that relate to the physical performance of activities, such as how the client is able to meet activities of daily living, demonstration of cognitive abilities, and social functioning. A comprehensive assessment encompasses all of the assessment data for the client. The focused assessment relies on one area of functioning such as the respiratory system if a client is having an asthma attack. The database assessment is performed during the initial history and physical portion of the client's illness and represents a comprehensive and all inclusive initial collection of data. |
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Term
Which is the best example of a nursing diagnosis?
Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast.
Cellulitis related to infection as evidenced by warm, reddened skin.
Ineffective Airway Clearance as evidenced by client not speaking.
Gastroesophageal Reflux related to low stomach pH as evidenced by foul breath and burning sensation in throat. |
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Definition
Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast.
Ineffective breastfeeding contains all the correct and necessary components of a nursing diagnosis. Both Gastroesophageal Reflux and Cellulitis are medical diagnoses. Ineffective Airway Clearance is an appropriate diagnostic label. However, a client not speaking does not match the diagnosis. |
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Term
| The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factors should the nurse identify as strengths of the client? Select all that apply. |
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Definition
The client has been accompanied by family members to every appointment.
The client states a belief in a reward in heaven after death.
The client has demonstrated effective coping skills in the past.
The client's support by family members, a belief in an afterlife, and demonstration of effective coping skills in the past are indications that the client will be able to cope with this illness. The client's belief in never asking for help will cause excessive isolation from others. The client's long history of health problems may have exhausted the client's physical and mental resources. |
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Term
| An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client? |
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Definition
Time-lapsed assessment
A time-lapsed assessment is scheduled to compare a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time are scheduled for this type of check. An emergency assessment is conducted if the client is having an emergency such as chest pain or hemorrhaging from the hand. Focused assessment is performed on clients focusing on the system or systems involved in the client's problem. Developmental stage assessment is the process of mapping a child's performance compared with children of similar age. |
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Term
| Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? |
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Definition
Focused
The nurse conducts a focused assessment of the client with a specific identified problem. An initial assessment is conducted by the nurse to establish a baseline database and identify current health problems. The nurse performs an emergency assessment during a crisis to identify life-threatening problems. A time-lapse assessment is one in which the nurse reassesses a client to evaluate the client's progress since a previous assessment for the same condition. |
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Term
| The nurse is working toward developing a nursing diagnosis for a client. What will the nurse do first? |
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Definition
Identify the significant data
The first step in developing a nursing diagnosis is to look at the data for significant cues. After identifying significant data or cues, the nurse then groups the cues together to form meaningful clusters that describe specific client problems. Cluster interpretation involves synthesizing the cue clusters, to see the whole picture and attach meaning to the cluster. After developing the nursing diagnosis, the nurse should validate it with the client. |
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Term
| For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment? |
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Definition
Initial
The Joint Commission has mandated that each client have a documented nursing admission (initial) assessment that follows institutional policies. An initial assessment is comprehensive and covers both a client's physical and psychosocial health. A focused assessment is one that addresses one specific problem that has already been identified; this type of assessment is not mandated by the Joint Commission. |
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Term
| A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source? |
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Definition
Secondary
The primary source of information is the client. The client's spouse, friends, and test results would be secondary sources of data. There are no tertiary or quaternary sources of assessment data. |
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Term
| The nurse has completed a head-to-toe assessment of a client and has identified several nursing diagnoses. These diagnoses will primarily serve what function? |
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Definition
To describe a functional health problem
Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses. The purpose of establishing a nursing diagnosis is not to collaborate with the health care provider, identify medical problems, or to meet accreditation criteria. Nursing diagnoses relate to problems that the nurse can address independently using nursing interventions, so collaboration with the health care provider is not needed when developing them. Medical diagnoses, not nursing diagnoses, identify medical problems. Accreditation does not depend on establishing nursing diagnoses. |
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Term
| The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next? |
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Definition
Validate the data.
Data need to be validated when there are discrepancies (e.g., the client says there is no pain but the nonverbal behavior indicates that the client is experiencing pain). The nurse should not ignore the client's answer or the client's nonverbal behavior. The nurse should chart the assessment, but the priority is to validate the differences in the verbal communication and nonverbal behavior. |
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Term
| A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client? |
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Definition
Impaired Comfort
Acute pain in the abdomen disturbs all the systems of the body. Relieving the pain should be the nurse's first priority. According to Maslow, physiologic needs are the highest priority. The client may have Disturbed Body Image, Disturbed Sleep Pattern, or Activity Intolerance, but all these are secondary to pain. |
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Term
| When used in a nursing diagnosis, the descriptor "impaired" has which meaning? |
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Definition
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Term
| Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include? |
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Definition
Tracheobronchial suctioning
Based on the assessment of the client, the nurse should identify specific cues, such as thick secretions, excessive sputum, and coughing, that indicate a problem with the client's ability to maintain a clear airway. Tracheobronchial suctioning would be the appropriate intervention to clear the client’s airway. The nurse would increase fluids to thin secretions, not limit fluid intake for this client. As the client is experiencing difficulty breathing, not problems with ambulation, assisted ambulation is not necessary. The client is breathing independently; therefore, mechanical ventilation is not necessary. |
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Term
| A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis? |
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Definition
Ineffective Airway Clearance
Because wheezing, shortness of breath, and coughing are signs of a constricted airway, the nursing diagnosis of Ineffective Airway Clearance is the appropriate diagnosis. Bronchial pneumonia and Asthma Attack are both medical diagnoses. Acute Dyspnea is a symptom. |
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Term
| A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern? |
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Definition
Risk for Powerlessness
The most appropriate nursing diagnosis for the client is the Risk for Powerlessness. The client feels that the disease is not under the client's control and any personal efforts will not affect outcome. Disturbed Body Image is not an appropriate answer because the client does not seem to be concerned about the appearance of the body. Impaired Comfort is also not an appropriate nursing diagnosis because the client does not demonstrate any sign of discomfort. There is not enough indication that the client is at risk for suicide. |
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Term
| A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem? |
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Definition
Disturbed Body Image related to loss of hair
The client has a problem with body image because of the loss of hair. The evidence would be the client's statement. The etiology cannot be a medical diagnosis, so the etiology of breast cancer would be incorrect. The other two statements do not contain an etiology. Nursing diagnoses must identify an etiology to direct the client's care. |
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Term
| After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? |
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Definition
Actual
"Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual nursing diagnosis, because it describes a human response to a health problem that is being manifested. A health promotion nursing diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A possible nursing diagnosis is made when not enough evidence supports the presence of the problem, but the nurse concludes that it is highly probable and wants to collect more information. |
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Term
The nurse has been assigned to a group of clients. Which client should be the nurse’s priority?
An 82-year-old client with emphysema who is receiving 2 liters of oxygen and is concerned about a pulse oximetry reading of 91%.
A 68-year-old client who had total hip replacement surgery 6 hours ago and is reporting moderate discomfort at the surgical site.
A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue.
A 48-year-old client with a hemoglobin of 9.5 g/dl (95 g/l) who is receiving ferrous sulfate supplements and is reporting feeling tired. |
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Definition
A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue.
The client receiving the intravenous antibiotic may be experiencing a possible airway obstruction secondary to an allergic reaction and should be the nurses first priority. Caring for a postoperative client reporting pain is important, but the client is not at risk of further deterioration if not cared for immediately. A client with an oxygen saturation of 91% is within normal limits and not the nurse's priority. A client with a low hemoglobin and symptoms of anemia is not in eminent danger and not the nurse's first priority. |
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Term
| When developing nursing diagnoses, the nurse should focus on which area? |
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Definition
Human responses to actual or potential health problems
The main focus of nursing diagnoses is on monitoring human responses to actual or potential health problems, whereas the main focus of medical diagnoses and collaborative problems is on monitoring the pathophysiological responses of body organs or systems. Actions to be initiated for treatment are the main focus for interventions or treatment. Collaboration with the health care provider to validate the problem reflects medical diagnoses or collaborative problems. |
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Term
| A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing, for which the nurse identifies several nursing diagnostic labels, including Ineffective Breathing Pattern and Impaired Gas Exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern? |
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Definition
Activity-exercise
Nursing diagnoses involving ineffective breathing pattern and impaired gas exchange would be organized under the pattern of activity-exercise, which addresses the pattern of activity, exercise, leisure, recreation, and activities of daily living. Nutritional-metabolic involves nursing diagnoses associated with weight, eating, fluids, and skin and tissue integrity. Coping-stress tolerance addresses coping, resilience, suicide, and self-mutilation. Cognitive-perceptual addresses pain, neurological issues, impulse control, knowledge, and decision-making. |
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Term
| A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem? |
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Definition
Ineffective Health Maintenance related to client's denial of illness
The most appropriate diagnosis is Ineffective Health Maintenance related to client's denial of illness. The data point to the fact that the client is not managing the diabetes, since the client denies that a problem exists. The client is at risk for unstable blood glucose, but the client's denial is the underlying problem. Risk for Injury relates to safety issues. It is also inappropriate documentation to say the client is "mismanaging" the illness. Ineffective Coping could be an appropriate diagnosis, but the client is not "unable" to manage the illness, just unwilling. |
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Term
| A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client’s defecation history. This is an example of: |
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Definition
premature closure.
Premature closure is when the nurse selects a nursing diagnosis before analyzing all of the pertinent information in the client's case. The nurse did not investigate any other information in this case before making a diagnosis. Inconsistent cues occur when the meaning attached to one cue may be altered based on another cue. The nurse in this case only considered one cue, so inconsistent cues could not be the correct answer. Clustering of cues is a clustering of data; this nurse has only one cue, so the nurse cannot cluster data or interpret data clusters. |
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Term
| Which best describes the purpose of nursing diagnoses? |
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Definition
Identification of client problems that nurses can treat independently
Nursing diagnoses are written to describe client problems that nurses can treat independently. Medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Collaborative problems require that a nurse work with other health care professionals, and the treatment comes from nursing, medicine, and other disciplines. Nursing diagnoses identify actual and potential client problems. |
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