Unit 4 Nursing Exam
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. What would you like to do?
When learning how to implement the nursing
process into a plan of care for a client, the student nurse realizes that partof the purpose of the nursing process is to:
- A. Deliver
- care to a client in an organized way.
- B. Implement a plan that is close to
- the medical model.
- C.*Identify client needs and deliver care
- to meet those needs.
- D. Make sure that standardized care is
- available to clients.
The nurse is performing a dressing change for a
client and notices that there is a new area of skin breakdown near the site of the dressing.
On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process?
- A.* Assessment
- B. Diagnosis
- C. Implementation
- D. Evaluation
A nurse is performing an initial
assessment on a new admission. Which of the following is part of the database?
(Select all that apply.)
- A.* Reports
- from physical therapy the client received as an outpatient
- B.* Documentation of the nurse's physical
- C. Physician's order
- D.* A list of current medications
- E.* Information about the client's
- cultural preference
- F. Discharge instructions
The nurse is taking information for the client's
database. The client is not very talkative; is pale, diaphoretic, and restless
in the bed; and tells the nurse to just "leave me alone." Which ofthe following is subjective data?
- A. Restlessness
- B.* "Leave me alone"
- C. Not talkative
- D. Pale and diaphoretic
The nurse is collecting information from a
client's family. The client is confused and not able to contribute to the
conversation. The spouse states, "This is not his normal behavior."
The nurse documents this as which of the following?
- A. Inference
- B. Subjective data
- C.* Objective data
- D. Secondary subjective data
- ???????????? CHECK ON THIS
A nurse is providing a back rub to a client just
after administering a pain medication, with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is
this nurse implementing?
- A. Assessment
- B. Diagnosis
- C.* Implementation
- D. Evaluation
A nurse has just been informed that a new
admission is coming to the unit. According to the 2005 JCAHO requirements, how long does the nurse have to complete a physical assessment and have a
documented history and physical on the chart?
- A. 1
- B. 12 hours
- C. 48 hours
- D.* 24 hours
An infant has been admitted to the pediatric
unit. The parents are quite worried and upset, and the grandmother is also
present. In this situation, what would be the best source of data?
- A. Medical
- record from the child's birth
- B. Grandmother, since the parents are
- C.* Parents
- D. Admitting physician
A client was admitted just prior to the shift
change. The admitting nurse reported most of the information to oncoming staff,
but did not have all of the client's past records. The second nurse is
completing the assessment and database and continues to question the client
about much of the same information as the previous nurse. The client says,
"Why don't you people talk to each other and quit asking the same things over
and over?" The best response of the nurse is:
- A. "In
- order to make sure all of your information is complete, I need to ask these
- B.* "You're right. Let me know if
- there's anything you need right now."
- C. "I'll be done shortly, just
- give me a few more minutes."
- D."You shouldn't be upset. We're
- only doing our jobs."
The nurse makes this entry in the client's
chart: "Client avoids eye contact and gives only vague, nonspecific
answers to direct questioning by the professional staff. However, is quite
animated (laughs aloud, smiles, uses hand gestures) in conversation with
spouse." This is an example of which method of data collection?
- A. Examining
- B. Interviewing
- C. Listening
- D.* Observing
A nurse has worked in the trauma critical
care area for several years. Which of the following noises may become
indiscriminate for this particular nurse?
- A. A
- client with audible breathing
- B. Moaning of a client in pain
- C.* Whirring of ventilators
- D. Co-workers discussing their clients'
A client has been using the call light
routinely throughout the evening. Upon entering the room, the nurse observes
the following details. Organize them according to priority sequencing (1 is
first priority; 6 is least priority).
- 1. Family is at bedside.
- 2. The IV pump is running on battery.
- 3. ECG monitor shows tachycardia.
- 4. Client is pale and restless.
- 5. O2 tubing is not attached to wall
- 6. Bedding is damp and soiled.
- Answer: 6, 4, 2, 1, 3, 5
MC During an initial interview, the client
makes this statement: "I don't understand why I have to have surgery, I'm
really not that sick or in pain right now." The nurse's best response is:
- A. "It's
- OK to be worried. Surgery is a big step."
- B.* "What kind of questions do you
- have about your surgery?"
- C. "I think these are things you
- should be asking your doctor."
- D. "Have you had surgery
The nurse is taking a health history from
a client who has complications from chronic asthma. Which of the following is
an example of an open-ended question?
- A.* "How would you describe your sleep pattern?"
- B. "Can you describe your coughing pattern?"
- C. "Is there anything that makes your breathing worse?"
- D. "What medications are you on?"
Wanting to know more about the client's
pain experience, the nurse continues to explore different questioning
techniques. Which of the following is the best example of an open-ended question
for this situation?
- A. "Is your pain worse at night?"
- B. "What brought you to the clinic?"
- C.* "How has the pain impacted your life?"
- D. "You're feeling down about having pain, aren't you?"
A client is coming in to the clinic for
the first time. In order for the nurse to allow the client the most comfort
during the interview, the nurse should:
- A.* Sit next to the client, a few feet apart.
- B. Sit behind a desk.
- C. Stand at the side of the client's chair.
- D. Stand at the counter to take notes
- during the interview.
A client comes into the emergency
department with a non-life-threatening wound to the hand that will require stitches. The department is quite busy with other clients, their families, and
other people in the waiting room. The best way for the nurse to conduct an interview with this client is to:
- A. Have the client wait until the department quiets down, since the wound is not too serious.
- B. Tell the client to wait in the waiting room and fill out the paperwork.
- C.* Draw curtains around the client and nurse to provide as much privacy as possible.
- D. Make sure the client's back is to rest of the room so as not to be heard by passersby.
MC A client has been admitted for acute
dehydration, secondary to nausea and diarrhea. When is the best time for the
nurse to conduct this client's interview?
- A. As soon as the client gets to the floor
- B.* After the client has settled in and
- been oriented to the room
- C. When the family is available to help
- D. After the client has been medicated
A nurse has been assigned a new client who
cannot speak English. In order that the client receives accurate information,
the nurse should:
- A. Have a member of the housekeeping staff who speaks the same language translate.
- B.* Use the translation services supplied by the hospital.
- C. Make sure a family member who does speak English is available.
- D. Conduct the interview using hand gestures.
A nursing student is meeting an assigned
client for the first time. In order to begin the establishment of rapport, the
best statement by the student is:
- A.* "Hello, I'm your nursing student and I'll be helping to take care of you today."
- B. "You're lucky, you have
- students and nurses taking care of you today."
- C. "Good morning, is there
- anything you need right now?"
- D. "Hi. If you need anything,
- either your nurse or I will get it for you."
The nurse has just completed an admission
interview with a new client. Which response by the nurse is an example of a
remark used during the closing phase of the interview?
- A.* "I'm going to set up your physical assessment now. Do you have any questions?"
- B. "Tell me more about how you feel."
- C. "Could you give examples of what types of other treatments you've had?"
- D. "Is there anything you're worried about?"
During an assessment interview, the nurse
understands that the client has decided not to take the physician's advice about
an elective surgical procedure. The client shares that this is "just not
part of what I have in mind for my life's goals." This would fall into
which of Gordon's functional health patterns?
- A. Cognitive/perceptual pattern
- B. Coping/stress-tolerance pattern
- C. Health-perception/health-management pattern
- D.* Value/belief pattern
A client comes to the emergency department
with injuries to her upper shoulders and back area. When questioned about how
the injuries occurred, the client becomes less talkative and states that she
"fell." The client has a history of frequent ED visits, always with
believable excuses about how her injuries occurred. The nurse begins to suspect
that this client is a victim of abuse. This is an example of the nurse making
which of the following?
- A. Observation
- of cues
- B. Validation
- C.* Inference
- D. Judgment
A nursing student is learning how to
implement the nursing process in the clinical area. The purpose of the
diagnosis phase includes which of the following? (Select all that apply.)
- A.* Develop a list of problems.
- B.* Identify client strengths.
- C. Develop a plan.
- D. Specify goals and outcomes.
- E.* Identify problems that can be prevented.
The nurse makes the decision to look at
alternatives for wound care with a client who has a stasis ulcer that has been
treated over the past 2 weeks. The nurse was hopeful to see some improvement by
this time. This represents which phase of the nursing process?
- A. Diagnosis
- B. Implementation
- C.* Evaluation
- D. Assessment
A nurse is working in the operating room
with a client just prior to the procedure. While setting up for the procedure,
the nurse notices that the client has become unresponsive and respirations have
become shallow. What type of assessment would be necessary in this situation?
- A. Initial assessment
- B. Problem-focused assessment
- C.* Emergency assessment
- D. Time-lapsed assessment
A nurse has delegated to a nurse's aide to
obtain vital signs for a newly admitted client. The aide reports the following:
temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure =
200/146. To validate the data, the best action by the nurse is:
- A.* Retake the vital signs.
- B. Call the physician.
- C. Continue with the physical assessment as soon as possible.
- D. Report the findings to the charge
What would you like to do?
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