Foundations Exam #2

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Overall health status of the U.S. population over the past few decades, disparities among ethnic and minorities have...

Remained a serious challenge locally and nationally

Eliminating disparities in the health status of people from diverse racial, ethnic, and cultural backgrounds has becomes one of the two most important priorities of Healthy people 2020 because populations with health disparties have

Increased incidence of disease

According to the Office of Minority Health (OMH), the thoughts, communications, actions, customs, beliefs, values and instituitions of racial, ethnic, religious, or social groups are known as...

culture

When asked to describe the differences between ethnicity and race, what should the student nurse explain?

Ethnicity refers to shared identity, whereas race is limited to biological attributes

Care that includes the nurse learning about cultural issues involved in the patient's health care belief system and enable patients and families to achieve meaningful and supportive care is known as...

Culturally competent care

The nurse is caring for a Native American who has had recent surgery. In the patient's culture, it is a sign of weakness to complain of pain. In the nurse's culture, people who are having pain ask for pain medicine. The nurse has assumed that the patient has not been having pain and does not need medication because he has not complained of pain. What is the nurse doing?

Utilizing cultural imposition by not asking the patient about his pain

In performing a cultural assessment, knowledge of a patient's country of origin and its history and ecological contexts is known as..

Ethnohistory

The nurse is caring for a patient of Asian descent who speaks very little English. The nurse is especially concerned and attempts to develop a trusting relationship with the patient. She does this knowing that..

Cultrual assessment is intrusive in contrast to other types of interviews

The nurse is caring for a patient who has emigrated from another country. The patient in need of abdominal surgery but seems reluctant to sign the surgical permits. What is one tactic that the nurse should use?

Determine the family social hierarchy

The nurse is caring for a Chinese patient who is reluctant to answer questions about her health background. The nurse ask the patient if she would like her husband present when health question are asked. The nurse does this knowing that the Chinese culture is a collectivistic and patrilineal culture. What does this mean?

Kinship is limited to the side of the father

The nurse is caring for a patient who does not speak English. She decides to use an interpreter to explain procedures and to answer questions that the patient may have. In performing the interview, what should the nurse do?

Direct question to the patient

Which statement is true relative to caring for a Hindu patient who is dying?

The family will place a drop of water on the patient's lips

In comparing American culture with Asian cultures, which of the following statements is true?

Asian communication can be ambiguous

When caring for a patient of a different culture, it is important for the nurse to understand that

Working within the established family heirarchy produces better outcomes

The nurse is caring for a member of the Jewish faith who needs to undergo a critical procedure on Saturday. The patient refusing the procedure because it is scheduled to be done on the Sabbath. The nurse impresses on the patient the urgency of the procedure, stating that delaying the procedure would put his life at risk. The patient continues to refuse. What should the nurse do?

Seek permission from the patient to contact the patient's rabbi.

The nurse is providing diabetic diet teaching to a Hispanic man and his wife. When the nurse is discussing foods that are acceptable, the wife continues to interrupt with statements like, "Oh, he doesn't eat that," or "All he eats rice and beans." What should the nurse do?

Refer the patient and his wife to a dietitian familiar with Spanish food choices.

Providing culturally congruent care means providing care that

Fits the patient's valued life patterns and set of meanings

Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care. These modes are "cultural care preservation or maintenance," "cultural care accommodation," and "cultural care repatterning." When assessing patients during the admission process, the nurse utilizes...

All these action modes simultaneously

Compare the following statements. Which are considered predominant in non-Western cultures?

Illness is an imbalance between humans and nature, Treatment of disease can be magico-religious based

Foster (1976) identified two distinct categories of healers cross-culturally, of the following characterisitics, which are congruent with the healing practices of naturalisitic practitioners?

Illness is impersonal and is due to biological forces, Illness is caused by alterations in the body equilibrium, Healing modalities include herbs, massage, and surgery.

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse

Completes a comprehensive database

A nurse using the problem-oriented approach to data collection will first

Focus on the patient's presenting situation

After reviewing the datatbase, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistant. With this is mind, what clinical decision should the nurse make?

Ask the nursing assistant to record the patient's vital signs before administering medications

Subjective data include

A patient's feelings, preceptions, and reported symptoms

A patient expresses fear of going home and being alone. Her vital signs are stable and her incision is nearly completely healed. The nurse can infer from the subjective data that..

The patient is apprehensive about discharge.

Which of the following methods of data collection is utilized to establish a patient's nursing database?

Physical examination

To gather information about a patient's home and working surroundings, the nurse will need to utilize which method of data collection?

Perform a thorough nursing health history

While interviewing an older female patient of Asian descent, the nurse notices that the patine looks at the ground when answering questions. The nurse should

Consider cultural differences during this assessment

After setting the agenda during a patient-centered interview, what will the nurse do?

Conduct a nursing health history

The nurse is attempting to prompt the patient to elaborate on her complaints of daytime fatigue. Which question should the nurse ask?

"What reasons do you think are contributing to your fatigue?"

Components of a nursing health history include

Patient expectations

White the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this complaint, thinking that no correlation has been noted between having a leg cast and developing restless sleep. A more theorectically sound approach would be to first

Ask the patient about his usual sleep patterns and the onset of having difficulty resting.

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). The nurse is performing what type of assessment approach in this situation?

Problem-oriented assessment

A nurse comparing data validation and data interpretation correctly explains the difference with which statement?

"Validation involves comparing data with other sources for accuracy."

Which scenario best illustrates the use of data validation when making an independent nursing clinical decision?

The nurse determines that she needs to remove a wound dressing when the patient reveals the time of the last dressing change, and she notices that present dressing is saturated with fresh and old blood

While completing an admission database, the nurse is interviewing a patient who states that he is allergic to latex. The most appropriate nursing action is to first

Ask the patient to describe the type of reaction

A patient verbalizes a low pain level 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's best action in response to her observation?

Ask the patient about the facial grimacing with movement

The nurse is assessing a patient with a hearing deficit. Where is the best place to conduct this interview?

The patient's room with the door closed

A nursing student is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which of the following actions made by the nursing student requires the nursing professor to intervene?

The nursing student is speaking only to the patient's daughter

Which of the following are examples of subjective data?

patient describing excitement about discharge, Patient's expression of fear regarding upcoming surgery

One purpose of using standard formal nursing diagnoses in practice is to...

Distinguish the nurse's role from the physician's role

Which diagnosis below NANDA-I approved?

Acute pain

Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumoia?

Impaired gas exchange related to alveolar-capillary membrane changes

The charge nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate to bathroom. The nurse needs to revise which part of the diagnostic statement?

Etiology

The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is known as

Diagnostic reasoning

A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture. The leg is stabilized in full leg cast. Otherwise, the patient has no other major injuries, is in good healthy, and complains only of moderate discomfort. What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided?

Acute pain

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function labs are normal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

Diagnosis

A patient with a spinal cord injury to seeking to enhance his urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nursing diagnosis Readiness for enhanced urinary elimination is which type of diagnosis?

Wellness

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The nursing assistant states she was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked & it has dropped even lower. The nurse first made an error is what phase of the nursing process?

Assessment

Identify the defining characterisitics in the nursing diagnosis statement: constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and complaints of abdominal pain.

abdominal distention

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, complaints of shortness of breath when getting out of bed, and a productive cough. What are the defining characteristics for the diagnostic label of Activity intolerance?

Decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed

Which of these selections is an etiology for Acute pain versus a defining characterisic?

Disruption of the tissue integrity

A patient of Middle Eastern descent has lost 5 lbs during hospitialization and states that the food offered is not allowed in his diet owing to religious preferences. Based on this information, an appropriate nursing diagnostic statement is imbalanced nutrition: less than body requirements related to

Decreased oral intake

After completing thorough assessment to formulate a patient database, the nurse should proceed to which step of the nursing process?

Diagnosis

A new graduate nurse is not sure what the heart sound is that she is listening to on a patient. To avoid diagnostic error, what should the nurse do?

Ask a more experienced nurse to listen also

Which of these findings, when evaluating another nurse developing a plan of care, should the charge nurse recognize as a source of diagnostic error?

Assigning diagnoses while completing the database

A patient exhibits the following symptoms: tachycardia, increased thrist, headache, decreased urine output, and increased body temperature. After analyzing these data, the nurse assigns which of the following nursing diagnoses?

Deficient fluid volume

Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?

"How many bowel movements a day have you had?"

A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

"Do you fee like you need to use the bathroom?"

After completing a thorough database and analyzing the data to identify any problems, the nurse should proceed to what step of the nursing process?

Planning

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. The nurse should revise the plan of care first by

Reassessing the patient

When planning patient care, a goal can be described as

A broad statement describing a desired change in patient behavior

When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realisitic to assign to a patient with pelvic fracture on bed rest? The patient will increase mobility by

Turning side to back to side with assistance every 2 hours

The following statements are on a patient's nursing care plan. Which of the following statement is written as an outcome?

The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

Which patient outcome statement includes all seven guidelines for writing goal and outcome statements?

The patient will feed self at all mealtimes today without complaints of shortness of breath

A nursing assessment for a patient with a spinal cord injury leads to several pertinent problems that a nurse can treat. While developing the plan of care, which nursing diagnosis is the highest priority for this patient?

Reflex urinary incontinence

The nurse is caring for seven patients this shift. After completing their assessments, the nurse states that he doesnt know where to begin in developing care plans for these patients. Which of the following is an appropriate suggestion by another nurse?

"Begin with the highest priority diganosis, then select appropriate interventions."

A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?

Involve the son in the plan of care as much as possible

Which of these outcomes would be most appropriate for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications?

Patient will have one soft, formed bowel movement by end of shift

The nurse recognizes that another that term for a collaborative nursing intervention is _____ intervention.

Interdependent

A registered nurse administers pain medication to a patient suffering from fractured ribs. What type of nursing intervention is the nurse implementing

Dependent

The nurse describes evidence-based practice as...

Implementing interventions based on scientific rationale

Which intervention is most appropriate for the nursing diagnostic statement, impaired verbal communication related to loss of facial motor control and decreased sensation?

Provide the patient with a writing board each shift

Which intervention is most appropriate for the nursing diagnostic statement, impaired skin integrity related to shearing forces?

Perform the ordered dressing change twice daily

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement, risk for falls?

Assist patient into and out of bed every 6 hours or as tolerated

Which of the following options correctly explains what the nurse should do with the plan of care for a patient after is is developed?

Communicate the plan of care to all health care professionals involved in the patient's care.

What is the first step in making consult?

Identify the problem

A hospital's wound nurse consultant made a recommedation for nurses on the unit to continue the patient's dressing changes as previously ordered. The nurses on the unit should incorporate this recommendation into the patient's plan of care by

Including dressing change instructions and frequency in the plan of care.

A nurse is planing care for a patient with a nursing diagnosis of impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. What factors does the nurse consider when prioritizing interventions?

Put all the patients' nursing diagnoses in order of priority, Consider time as an influencing factor, Do not change priorities once they've been established

In which step of the nursing process does the nurse provide nursing care interventions to patients

implmentation

The nurse defines a clincial guideline or protocol as a

Document that assists the clinician in making decisions and choosing interventions for specific health care problems or conditions

The standing orders for a patient include acetaminophen (tylenol) 650 mg every 4 hours prn for headache. After assessing the patient, identifying the need for heachache relief, and determining that the patient has not had Tylenol in the past 4 hours, the nurse

Administers the Tylenol

Before implementing any intervention, the nurse uses crictical thinking to

Determine whether an intervention is correct and approriate for the given situation

Which of the following is a nursing intervention?

Provide assistance while the patient walks in the hallway twice this shift with crutches

A patient recovering from a leg fracture after a fall states that he has dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. What is the priority nursing intervention for this patient?

Administer pain mediciation

The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. What does the nurse do just before changing the dressing?

Assesses the patient's readiness for the procedure

A patient visiting with family members in the waiting area tells the nurse that his stomach is not feeling good. Before intervening, what should the nurse do?

Ask the patient to return to his room so the nurse can inspect his abdomen

A newly admitted patient who morbidly asks the nurse to assist her to the bathroom for the first time. What should the nurse do first?

Review the patient's activity orders

Which of these interventions, to be included in the plan of care, is approriate for the patient out comes that states, "The patient will verbalize a pain level at 3 or below on a 0 to 10 scale throughout this shift"?

Teach the patient about side effects of pain medications.

What is the first intervention included on any patient's plan of care?

Reassess the patient

Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. what is the nurse's first action?

Assess the patient for other symptoms or problems, and then notify the health care provider

Which intervention is most appropriate for a patient who has a new onset of chest pain?

Reassess the patient because of the change in condition

Which is the appropriate initial intervention for the nursing diagnostic statement impaired skin integrity related to poor wound healing

Assess wound appearance each shift

The nurse establishes trust and talks with a school-aged patient before administering injections. The nurse is demonstrating which type of implementation skill?

Interpersonal

The nurse inserts an intravenous catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. This is demonstrating which type of implementation skills?

Psychomotor

A nurse employed in a staff development department is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the in-service, which of the following statements made by one of the nurses in the room requires the staff nurse to clarify the information provided?

"This sytem can help medical students determine the cost of the care they provide"

The nurse is intervening for an identified nursing diagnosis of Caregiver role strain. Which direct care nursing intervention is most appropriate?

Counseling About respite care options

The nurse is intervening for an identified nursing diagnosis of Risk for infection. Which direct care nursing intervention is most appropriate?

Teaching the family proper handwashing technique

which of the following are nursing interventions?

Reposition a patient who is on bed rest, Remind a patient to cough and deep breath after surgery

Which of the following are direct care interventions?

Turning a patient, Counseling a patient, Performing resuscitation, Teaching wound care

Before implementing care, the nurse needs to ensure that which resources are available?

Equipment, safe environment, patient readiness, assistive personnel

Which interventions are appropriate for the nursing diagnosis impaired tissue integrity related to poor wound healing secondary to diabetes

Teach the patinet about signs and symptoms of infection, perform dressing changes twice a day as ordered, administer medications to control the patient's blood sugar as ordered, teach the family how to perform dressing changes

In which step of the nursing process does the nurse determine if the patient's condition has improved and whether the patient has met the expected outcomes?

Evaluation

After completing a thorough database and carrying out the nursing interventions based on priority diagnoses, the nurse proceeds to which step of the nursing process?

Evaluation

A nursing student ask her nursing instructor to describe the primary purpose of evaluation. Which of the following statements made by the nursing instructor is most accurate?

"Nurses use evaluation to determine the effectiveness of nursing care."

After assessing the patient identifying the need for headache relief, the nurse administers acetaminophen (Tylenol) for the patient's headache. What is the nurse's next priority action for this patient?

Reassess the patient's pain level in 30 minutes

A nurse is getting ready to discharge to home and patient who has a nursing diagnosis of impaired physical mobility. Before discontinuing the patient's plan of care, what does the nurse need to do?

Evaluate whether patient goals and outcomes have been met

The nurse is evaluating whether patient goals and outcomes have been met. Which option below is an expected outcome for a patient with Impaired physical mobility?

The patient is able to ambulate in the hallway with crutches

The nurse is evaluation whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?

Absence of skin breakdown

What is the primary goal of the outcomes management for professional nurses?

To promote purposeful actions focused on improving a patient's health conditions

A new nurse states that she is confused about using evaluative measures when caring for a patients and asks the charge nurse for examples and an explanation. Which of the following is the most accurate response from the charge nurse?

"Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals."

The nurse is caring for a patient who has an open wound. When evaluation the progress of wound healing, what is the nurse's priority action?

Measure the wound and observe for readness, swelling or drainage

The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 at 1800. At 1400, the nurses notices that the dressing is saturated. What is the nurse's next action?

Revise the plan of care and change dressing now.

A goal for a patient with a diagnosis of Ineffective coping is to demonstrate effective coping skills. Which of these patient behaviors indicates that interventions perfomred to meet this outcome have been successful?

States he feels better talking with his family and friends

A nurse is providing education to patient about self-administering subcutaneous injections. Which of these patient statement indicates that the patient understands the instructions?

"My belly is good place to give my injection"

Which of these statements made by a patient who had Disturbed body image is the best indicator of the patient early acceptance of body image?

"I'll wear the blue dress. It matches my eyes"

Which of these options is a patient outcomes indication positive progress toward resolving the nursing diagnosis of Acute Confusion?

Patient correctly state names of family members in the room

A nurse identifies a nursing diagnosis of risk for falls when assessing a patient upon admission. The nurse and the patient agree that the goal is the patient to remain free from falls. However, the patient fall just before shift change. What is the nurse's priority action when evaluating the patient's plan of care?

Identify factors interfering with goal achievement

A patient was recently diagnosed with pneumonia. The nurse the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which of the following is an appropriate evaluative measure demonstrating progress toward this goal?

Lungs clear to auscultation following use of inhaler

A nurse adminstrator is at a meeting with nurses on the quality council. Several new members are sitting on the council. They ask the nurse administrate to clarify what a nursing-sensitive outcome is. Which is response by the nurse admnistrator best defines nursing-sensitive outcomes?

"Patient falls is an example of a nursing-sensitive outcome because they are directly affect by nursing interventions."

Which of the following are examples of evaluative measures that a nurse should utilize when determining the patient's response to nursing care?

Observations of wound healing, assessment of respiratory rate and depth, Blood pressure measurement, Patient's subjective report of feelings about a new diagnosis of cancer

Identify elements of the evaluation process

Collecting subjective and objective data to determine whether criteria or standards are met, Documenting findings, Termination continuing or revising the care plan

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