30 سؤال اختيارى على محاضرة nursing process

ملاحظة :فية اسئلة مش تبعنا فى المنهج

 تحميل الاسئلة+شرح الاجابة بصيغة الورد اضغط هنـــــــا

This set has 30 terms

 (1)During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?"

A. Introduction
B. Body
C. Closing
D. Orientation

 (2)The nurse is most likely to collect timely, specific information by asking which of the following questions?

A. "Would you describe what you are feeling?"
B. "How are you today?"
C. "What would you like to talk about?"
D. "Where does it hurt?"

 (3)The nurse should avoid asking the client which of the following leading questions during a client interview?

A. "What medication do you take at home?"
B. "You are really excited about the plastic surgery, aren't you?"
C. "Were you aware I've has this same type of surgery?"
D. "What would you like to talk about?"

 (4)The nurse needs to validate which of the following statements pertaining to an assigned client?

A. The client has a hard, raised, red lesion on his right hand.
B. A weight of 185 lbs. is recorded in the chart
C. The client reported an infected toe
D. The client's blood pressure is 124/70. It was 118/68 yesterday.

 (5)Which of the following items of subjective client data would be documented in the medical record by the nurse?

A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feel nauseated

 (6)A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift?

A. Nurse and client agree upon health care goals for the client
B. Nurse reviews the client's history on the medical record
C. Nurse explains to the client the purpose of each administered medication
D. Nurse rapidly reset priorities for client care based on a change in the client's condition

 (7)The client reports nausea and constipation. Which of the following would be the priority nursing action?

A. Collect a stool sample
B. Complete an abnormal assessment
C. Administer an anti-nausea medication
D. Notify the physician

 (8)The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following?

A. Incomplete data
B. Generalize from experience
C. Identifying with the client
D. Lack of clinical experience

 (9)The nurse notes that the client often sighs and says in a monotone voice, "I'm never going to get over this." When encouraged to participate in care, the client says, "I don't have the energy." The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply.

A. Hopelessness
B. Powerlessness
C. Interrupted sleep pattern
D. Disturbed self esteem
E. Self care deficit

 (10)Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis?

A. Grimacing
B. Anxiety
C. Oxygenation saturation 93%
D. Output 500 mL in 8 hours

 (11)Which desired outcome written by the nurse is correctly written and measurable?

A. Client will have a normal bowel pattern by April 2
B. The client will lose 4 lbs. within next 2 weeks
C. The nurse will provide skin care at least 3 times each day
D. The client will breathe better after resting for 10 minutes

 (12)The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care?

A. Nursing diagnosis/problem list
B. Nursing orders
C. Short-term goals
D. Long-term goals

 (13)Which of these is a correctly stated outcome goal written by the nurse?

A. The client will walk 2 miles daily by March 19
B. The client will understand how to give insulin by discharge
C. The client will regain their former state of health by April 1
D. The client achieve desired mobility by May 7

 (14)The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?

A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness during hospital stay
C. Client will state pain relieved within 30 minutes after medication
D. Pressure will be prevented by repositioning client every 2 hours

 (15)While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?

A. Help client into the chair but more quickly
B. Document client's vital signs taken just prior to moving the client
C. Help client back to bed immediately
D. Observe client's skin color and take another set of vital signs

 (16)After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods?

A. Return demonstration
B. Explanation
C. Achievement of 90 on written test
D. Have client explain produce to the family

 (17)The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult?

A. Formulate a nursing diagnosis of impaired gas exchange
B. Record in the medical record the distance a client ambulate in the hall
C. Write individualized nursing orders in the care plan
D. Compare client responses to the desired outcomes for pain relief

 (18)A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, "I'm tired of being sick. I wish I could end it all." What is the most accurate and informative way to record this data in a nursing progress note?

A. Client appears to be depressed, possibly suicidal
B. Client reports being tired of being ill and wants to die
C. Client does not want to live any longer and is tired of being ill
D. Client states, "I'm tired of being sick. I wish I could end it all."

 (19)The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?

A. Use Liquid PaperTM to "white out" the resolve diagnosis on the care plan
B. Recopy the care plan without the resolve diagnosis
C. Write a nursing process not indicating that the outcome goals have been achieved
D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date

 (20)The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should:

A. Formulate post-discharge nursing diagnoses
B. Draw conclusion about resolution of current client problems
C. Assess the client for baseline data to be used at the LTC facility
D. Plan the care that is needed in the LTC facility

 (21)A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?

A. Help the client to get settled and do the interview the next morning when the client is rested
B. Do the interview immediately, directing the majority of the questions to the client's spouse
C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns
D. Ask the charge nurse to interview the client while the admitting

(22)The nurse overhears an unlicensed assistive person (UAP) who has just been accepted to nursing school say to a client, "You must be so pleased with your progress." The nurse later explains to the UAP that this is an example of what type of question?

A. Close-ended question
B. Open-ended question
C. Leading question
D. Neutral question

.

(23)The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply.

A. Collect and organize client information
B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses
E. Develop client goals

(24)The functional health pattern assessment data states: "Eats three meals a day and is of normal weight for height." The nurse should draw which of the following conclusions about this data? Select all that apply.

A. Client has an actual health problem
B. Client has a wellness diagnosis
C. Collaborative health problem needs to be written
D. Possible nursing diagnosis exists
E. Specific questions about the diet should be asked next

 (25)For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?

A. Discomfort
B. Deficit
C. Feeding
D. Fractured wrists

 (26)The nurse would make which of the following inferences after performing the appropriate client assessment?

A. Client is hypotensive
B. Respiratory rate of 20 breaths per minute
C. Oxygen saturation of 95%
D. Client relays anxiety about blood work

 (27)The nurse would write which of the following outcome statements for a client starting an exercise program?

A. Client will walk quickly three times a day
B. Client will be able to walk a mile
C. Client will have no alteration in breathing during the walk
D. Client will progress to walking a 20-minute mile in one month

 (28)The nurse decides it would be beneficial to the client to allow the client's infant granddaughter to visit before the client's scheduled heart transplant. Before implementing this intervention the nurse should collaborate with which of the following? Select all that apply.

A. Client and Family
B. Other nursing staff on the unit
C. Security department
D. Hospital administration
E. This is not a collaborative intervention so no collaboration will be needed prior to implementation

 (29)The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time?

A. Assessment
B. Planning
C. Implementation
D. Evaluation

 (30)A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client's progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write?

A. Client understands the signs of impaired circulation
B. Goal met: Client cited numbness and tingling as sign of impaired circulation
C. Goal not met: Client able to name only two signs of impaired circulation
D. Goal not met: Client unable to describe signs of impaired circulation