After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases?
Question 1 After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases?
Evaluation
Implementing
Formulating a nursing diagnosis
Planning
Assessment
Question 2 Which statement below best documents objective findings?
Crackles in lower lobes bilaterally, with high-pitched wheezes throughout lung fields.
Complains of feeling short of breath.
Dizziness and sensation of impending doom.
Reports history of cardiac surgery in 2008.
Question 3 Which action would be the best for the nurse at the beginning of the nurse client encounter for a client visiting a walk in clinic for complaints of a fever?
Lymph nodes examination
Head and neck examination
Vital signs including temperature
Subjective data collection
Question 4 The nurse is reviewing a client’s medical record and notes the various forms of information. The nurse understands that which of the following is subjective data?
Results of radiographic studies
Laboratory analysis reports
Physical examination results
Family medical history
Question 5 Verifying that data is correct is a method of validating findings to be certain of accuracy. Which methods of validation are best? Select all the apply.
Re-phrase questions if you didn’t understand the patient’s meaning.
When assessing a fully oriented adult patient, ask the accompanying family member to confirm all answers as you collect subjective data.
Compare your subective and objective data to see if they agree.
Correct your current assessment findings to correlate with the physical examination done by the physician.
Verify the data by asking another nurse to confirm a specific objective finding.
Question 6 When documenting findings of an abdominal assessment, which of the methods below are best?
Abnormal B.S. in 3 of 4 quadrants.
Complains of tenderness in right lower quadrant with deep palpation. Denies pain/tenderness in other quadrants.
Signs of appendicitis present, with pain in right lower quadrant.
Good bowel sounds in all quadrants, fair amount of tenderness on deep palpatio
Question 7 In thinking critically, nurses need to have a sense of urgency, yet put all facts in the context of the evolving situation.
The daughter of a geriatric patient rushes to the nursing station and shouts, “I need someone to come now! I think mother has stopped breathing!” The charge nurse hurries to the room and sees the patient lying calmly in bed with respiratory rate of 28. Which response by the nurse shows evidence of critical thinking?
The nurse states, “Looks like the problem has resolved!” and plans to monitor the situation closely over the next few hours.
The nurse documents that the patient’s daughter seems paranoid about the mother’s condition.
The nurse does a quick subjective assessment to determine if the patient agreed that she had stopped breathing at any point recently.
The nurse thanks the daughter and asks what it was that made her feel that there was a problem with her mother’s breathing.
Question 8 The nurse palpates a client’s pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. It had previously been regular. How should the nurse first follow up this assessment finding?
Palpate the client’s ulnar pulse and compare with the femoral pulse
Auscultate the client’s apical pulse for a full minute.
Notify the physician that the client may be in atrial fibrillation.
Reposition the client in a side-lying position.
Question 9 Which of the following are true concerning pain? Select all that apply.
A patient who is sleeping is clearly not in significant pain
Making certain that patients do not become addicted to analgesics is vital in treating terminal patients with chronic pain.
Peripheral nerve endings which transmit pain are called nociceptors
Pain is normal in the elderly.
Getting the family’s input on how much pain the patient is in is especially for adults.
Pain is what the patient says it is.
Question 10 A client has been admitted following an unexplained weiht loss of 15 points over the last 3 months. How should the nurse best assess the subjective component of the client’s nutritional status?
Ask the patient to explain the concept behind MyPlate.
Elicit the client’s favorite foods.
Obtain a 24-hour dietary recall.
Ask about the contents of a typical meal.
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