Question 1

The nurse clarifies that nursing orders are also called:

Accepted Answer

A)  goals. 
B)  qualifiers. 
C)  interventions. 
D)  measurement criteria. 
A)  goals. 
B)  qualifiers. 
C)  interventions. 
D)  measurement criteria. C

Question 2

Appropriate nursing roles in the initial assessment would include: (Select all that apply.)

Accepted Answer

A)  LPN obtains the vital signs of a new patient. 
B)  RN performs a complete physical assessment. 
C)  LPN organizes data into a database. 
D)  RN reviews the patient's chart for past medical/surgical history. 
E)  LVN contributes ongoing assessments. 
A)  LPN obtains the vital signs of a new patient. 
B)  RN performs a complete physical assessment. 
C)  LPN organizes data into a database. 
D)  RN reviews the patient's chart for past medical/surgical history. 
E)  LVN contributes ongoing assessments. A, B, D, E

Question 3

The statements that are correctly stated as expected outcomes are: (Select all that apply.)

Accepted Answer

A)  Patient will be able to void in the bathroom independently. 
B)  Patient will be able to ambulate using a walker independently within 3 days. 
C)  The nurse will assist the patient to the bathroom three times a day. 
D)  Patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours. 
E)  The family will bring food from home to improve patient appetite. 
A)  Patient will be able to void in the bathroom independently. 
B)  Patient will be able to ambulate using a walker independently within 3 days. 
C)  The nurse will assist the patient to the bathroom three times a day. 
D)  Patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours. 
E)  The family will bring food from home to improve patient appetite. B, D

Question 4

The nurse takes into consideration that the difference between a sign and a symptom is that a sign is:

Accepted Answer

A)  subjective data. 
B)  unreliable because it depends on translation. 
C)  can be verified by examination. 
D)  something a patient reports that is verified by a relative. 
A)  subjective data. 
B)  unreliable because it depends on translation. 
C)  can be verified by examination. 
D)  something a patient reports that is verified by a relative.

Question 5

A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is:

Accepted Answer

A)  Airway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
B)  Airway clearance, ineffective, related to right lower lobe pneumonia as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
C)  Right lower lobe pneumonia, related to airway clearance, ineffective, as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
D)  Expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung related to right lower lobe pneumonia as evidenced by airway clearance. 
A)  Airway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
B)  Airway clearance, ineffective, related to right lower lobe pneumonia as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
C)  Right lower lobe pneumonia, related to airway clearance, ineffective, as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. 
D)  Expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung related to right lower lobe pneumonia as evidenced by airway clearance.

Question 6

A nursing diagnosis consists of:

Accepted Answer

A)  the physician's medical diagnosis listed as the nursing diagnosis. 
B)  diagnostic labels formulated by the North American Nursing Diagnosis Association-International (NANDA-I). 
C)  the patient's explanation of his or her "chief complaint" or "current complaint." 
D)  the results of the nursing assessment without consideration of doctor's orders. 
A)  the physician's medical diagnosis listed as the nursing diagnosis. 
B)  diagnostic labels formulated by the North American Nursing Diagnosis Association-International (NANDA-I). 
C)  the patient's explanation of his or her "chief complaint" or "current complaint." 
D)  the results of the nursing assessment without consideration of doctor's orders.

Question 7

An example of a structured format for gathering data that aids in forming a database is:

Accepted Answer

A)  North American Nursing Diagnosis Association-International (NANDA-I). 
B)  Maslow's hierarchy. 
C)  following the information in the history and physical. 
D)  Gordon's 11 Health Patterns. 
A)  North American Nursing Diagnosis Association-International (NANDA-I). 
B)  Maslow's hierarchy. 
C)  following the information in the history and physical. 
D)  Gordon's 11 Health Patterns.

Question 8

The nurse performing an admission interview on an elderly person should:

Accepted Answer

A)  rush through the interview to avoid tiring the patient. 
B)  direct questions to the family rather than the patient. 
C)  allow more time for a response to questions. 
D)  prompt the patient to speed recall. 
A)  rush through the interview to avoid tiring the patient. 
B)  direct questions to the family rather than the patient. 
C)  allow more time for a response to questions. 
D)  prompt the patient to speed recall.

Question 9

The North American Nursing Diagnosis Association-I (NANDA-I) list is revised and updated every:

Accepted Answer

A)  year. 
B)  2 years. 
C)  3 years. 
D)  5 years. 
A)  year. 
B)  2 years. 
C)  3 years. 
D)  5 years.

Question 10

A patient has a nursing diagnosis of Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30-pounds over the last 6 months. An appropriate short-term goal for this patient is to:

Accepted Answer

A)  eat 50% of six small meals each day by the end of 1 week. 
B)  demonstrate progressive weight gain over 6 months. 
C)  eat all of the meals prepared during admission. 
D)  verbalize understanding of caloric needs and intention to eat. 
A)  eat 50% of six small meals each day by the end of 1 week. 
B)  demonstrate progressive weight gain over 6 months. 
C)  eat all of the meals prepared during admission. 
D)  verbalize understanding of caloric needs and intention to eat.

Question 11

If a patient has several nursing diagnoses, the nurse will first:

Accepted Answer

A)  consult with the doctor regarding which diagnosis is most important. 
B)  devise nursing interventions for the most quickly solved problems. 
C)  prioritize the nursing problems according to Maslow's hierarchy of needs. 
D)  review the patient's medical prescriptions and other drugs being taken. 
A)  consult with the doctor regarding which diagnosis is most important. 
B)  devise nursing interventions for the most quickly solved problems. 
C)  prioritize the nursing problems according to Maslow's hierarchy of needs. 
D)  review the patient's medical prescriptions and other drugs being taken.

Question 12

The nurse designs the goals for patients in long-term facilities to be:

Accepted Answer

A)  conditional. 
B)  open ended. 
C)  based on behavioral norms. 
D)  long-term. 
A)  conditional. 
B)  open ended. 
C)  based on behavioral norms. 
D)  long-term.

Question 13

When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _______ data.

Accepted Answer

A)  objective 
B)  medical 
C)  subjective 
D)  adjunct 
A)  objective 
B)  medical 
C)  subjective 
D)  adjunct

Question 14

During the assessment phase of the nursing process, the nurse

Accepted Answer

A)  develops a care plan to meet the patient's nursing needs. 
B)  begins to formulate plans for providing nursing intervention. 
C)  establishes a nursing diagnosis for the nursing care plan. 
D)  gathers, organizes, and documents data in a logical database. 
A)  develops a care plan to meet the patient's nursing needs. 
B)  begins to formulate plans for providing nursing intervention. 
C)  establishes a nursing diagnosis for the nursing care plan. 
D)  gathers, organizes, and documents data in a logical database.

Question 15

The seven domains of the Nursing Interventions Classification (NIC) taxonomy include: (Select all that apply.)

Accepted Answer

A)  community. 
B)  health system. 
C)  socioeconomic level. 
D)  safety. 
E)  behavioral. 
A)  community. 
B)  health system. 
C)  socioeconomic level. 
D)  safety. 
E)  behavioral.

Question 16

A nursing care plan consists of:

Accepted Answer

A)  nursing orders for individualized interventions to assist the patient to meet expected outcomes. 
B)  orders for diagnostic and therapeutic procedures such as laboratory tests or radiographs. 
C)  the physician's history and physical examination, as well as medical diagnoses. 
D)  laboratory and radiograph reports, pathology reports, and the medication record. 
A)  nursing orders for individualized interventions to assist the patient to meet expected outcomes. 
B)  orders for diagnostic and therapeutic procedures such as laboratory tests or radiographs. 
C)  the physician's history and physical examination, as well as medical diagnoses. 
D)  laboratory and radiograph reports, pathology reports, and the medication record.

Question 17

A patient with visual impairment is identified as at risk for falls related to blindness. An appropriate intervention would be to:

Accepted Answer

A)  assist the patient with feeding herself at the end of the meal. 
B)  arrange furnishings in room to provide clear pathways and orient the patient to these. 
C)  take the patient's blood pressure before she gets up in the morning. 
D)  report any falls immediately to the charge nurse and the doctor. 
A)  assist the patient with feeding herself at the end of the meal. 
B)  arrange furnishings in room to provide clear pathways and orient the patient to these. 
C)  take the patient's blood pressure before she gets up in the morning. 
D)  report any falls immediately to the charge nurse and the doctor.

Question 18

Aside from the information obtained from the patient (primary source) in the admission interview, the nurse will also access: (Select all that apply.)

Accepted Answer

A)  the patient's family. 
B)  a reliable and up-to-date reference book. 
C)  the admission note. 
D)  the physician's history and physical. 
E)  an observation of the patient for non-verbal clues. 
A)  the patient's family. 
B)  a reliable and up-to-date reference book. 
C)  the admission note. 
D)  the physician's history and physical. 
E)  an observation of the patient for non-verbal clues.

Question 19

Conclusions that have been made based on observed data are __________.

Accepted Answer

inferences
Inference

Question 20

An elderly patient with a medical diagnosis of chronic lung disease has developed pneumonia. She is coughing frequently and expectorating thick, sticky secretions. She is very short of breath, even with oxygen running, and she is exhausted and says she "can't breathe." Based on this information, an appropriately worded nursing diagnosis for this patient is

Accepted Answer

A)  Airway clearance, ineffective, related to lung secretions as evidenced by cough and shortness of breath. 
B)  Pneumonia, cough, and shortness of breath related to chronic lung disease. 
C)  Difficulty breathing not relieved by oxygen and evidenced by shortness of breath. 
D)  Cough and shortness of breath caused by pneumonia, chronic lung disease, advanced age, and exhaustion. 
A)  Airway clearance, ineffective, related to lung secretions as evidenced by cough and shortness of breath. 
B)  Pneumonia, cough, and shortness of breath related to chronic lung disease. 
C)  Difficulty breathing not relieved by oxygen and evidenced by shortness of breath. 
D)  Cough and shortness of breath caused by pneumonia, chronic lung disease, advanced age, and exhaustion.

Exam 5: Assessment, Nursing Diagnosis, and Planning

The nurse clarifies that nursing orders are also called:

Appropriate nursing roles in the initial assessment would include: (Select all that apply.)

The statements that are correctly stated as expected outcomes are: (Select all that apply.)

The nurse takes into consideration that the difference between a sign and a symptom is that a sign is:

A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is:

A nursing diagnosis consists of:

An example of a structured format for gathering data that aids in forming a database is:

The nurse performing an admission interview on an elderly person should:

The North American Nursing Diagnosis Association-I (NANDA-I) list is revised and updated every:

A patient has a nursing diagnosis of Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30-pounds over the last 6 months. An appropriate short-term goal for this patient is to:

If a patient has several nursing diagnoses, the nurse will first:

The nurse designs the goals for patients in long-term facilities to be:

When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _______ data.

During the assessment phase of the nursing process, the nurse

The seven domains of the Nursing Interventions Classification (NIC) taxonomy include: (Select all that apply.)

A nursing care plan consists of:

A patient with visual impairment is identified as at risk for falls related to blindness. An appropriate intervention would be to:

Aside from the information obtained from the patient (primary source) in the admission interview, the nurse will also access: (Select all that apply.)

Conclusions that have been made based on observed data are __________.

Nursing and the Health Care System

Concepts of Health, Illness, Stress, and Health Promotion

Legal and Ethical Aspects of Nursing

Nursing Process and Critical Thinking

Implementation and Evaluation

Documentation of Nursing Care

Communication and the Nurse-Patient Relationship

Patient Teaching for Health Promotion

Delegation, Leadership, and Management

Growth and Development: Infancy Through Adolescence

Adulthood and the Family

Promoting Healthy Adaptation to Aging

Cultural and Spiritual Aspects of Patient Care

Loss, Grief, the Dying Patient, and Palliative Care

Infection Prevention and Control: Protective Mechanisms and Asepsis

Infection Prevention and Control in the Hospital and Home

Lifting, Moving, and Positioning Patients

Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers

Patient Environment and Safety

Measuring Vital Signs

Assessing Health Status

Admitting, Transferring, and Discharging Patients

Diagnostic Tests and Specimen Collection

Fluid, Electrolyte, and Acid–Base Balance

Concepts of Basic Nutrition and Cultural Considerations

Diet Therapy and Assisted Feeding

Assisting with Respiration and Oxygen Delivery

Promoting Urinary Elimination

Promoting Bowel Elimination

Pain, Comfort, and Sleep

Complementary and Alternative Therapies

Pharmacology and Preparation for Drug Administration

Administering Oral, Topical, and Inhalant Medications

Administering Intradermal, Subcutaneous, and Intramuscular Injections

Administering Intravenous Solutions and Medications

Care of the Surgical Patient

Providing Wound Care and Treating Pressure Ulcers

Promoting Musculoskeletal Function

Common Physical Care Problems of the Elderly

Common Psychosocial Care Problems of the Elderly

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