Question 1

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

Accepted Answer

A) The patient's room with the door closed. 
B) The waiting area with the television turned off. 
C) The patient's room before administration of pain medication. 
D) The patient's room while the occupational therapist is working on leg exercises. 
A) The patient's room with the door closed. 
B) The waiting area with the television turned off. 
C) The patient's room before administration of pain medication. 
D) The patient's room while the occupational therapist is working on leg exercises. A

Question 2

A patient verbalizes a low pain level of 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?

Accepted Answer

A) Proceed to the next patient's room while making rounds. 
B) Offer a massage because the patient does not want any more pain medicine. 
C) Administer the pain medication ordered for moderate to severe pain. 
D) Ask the patient about the facial grimacing with movement. 
A) Proceed to the next patient's room while making rounds. 
B) Offer a massage because the patient does not want any more pain medicine. 
C) Administer the pain medication ordered for moderate to severe pain. 
D) Ask the patient about the facial grimacing with movement. D

Question 3

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

Accepted Answer

A) Risk for impaired skin integrity. 
B) Risk for infection. 
C) Spiritual distress. 
D) Reflex urinary incontinence. 
A) Risk for impaired skin integrity. 
B) Risk for infection. 
C) Spiritual distress. 
D) Reflex urinary incontinence. D

Question 4

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

Accepted Answer

A) Carefully review laboratory results. 
B) Conduct the physical assessment before collecting subjective information. 
C) Document a thorough nursing health history. 
D) Prolong the termination phase of the interview. 
A) Carefully review laboratory results. 
B) Conduct the physical assessment before collecting subjective information. 
C) Document a thorough nursing health history. 
D) Prolong the termination phase of the interview.

Question 5

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

Accepted Answer

A) Completes a comprehensive database. 
B) Identifies pertinent nursing diagnoses. 
C) Intervenes on the basis of patient goals and priorities of care. 
D) Determines whether outcomes have been achieved. 
A) Completes a comprehensive database. 
B) Identifies pertinent nursing diagnoses. 
C) Intervenes on the basis of patient goals and priorities of care. 
D) Determines whether outcomes have been achieved.

Question 6

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

Accepted Answer

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

Question 7

Subjective data include which of the following?

Accepted Answer

A) A patient's feelings,perceptions,and reported symptoms. 
B) A description of the patient's behaviour. 
C) Observations of a patient's health status. 
D) Measurements of a patient's health status. 
A) A patient's feelings,perceptions,and reported symptoms. 
B) A description of the patient's behaviour. 
C) Observations of a patient's health status. 
D) Measurements of a patient's health status.

Question 8

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

Accepted Answer

A) "Validation involves looking for patterns in professional standards." 
B) "Data interpretation involves discovering patterns in professional standards." 
C) "Validation involves comparing data with other sources for accuracy." 
D) "Data interpretation occurs before data validation." 
A) "Validation involves looking for patterns in professional standards." 
B) "Data interpretation involves discovering patterns in professional standards." 
C) "Validation involves comparing data with other sources for accuracy." 
D) "Data interpretation occurs before data validation."

Question 9

While 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.What would be a more theoretically sound first approach?

Accepted Answer

A) Document the sleep patterns and complaint in the patient's chart. 
B) Tell the patient you are just focused on the leg right now. 
C) Explain that a more thorough assessment will be needed next shift. 
D) Ask the patient about his usual sleep patterns and when the difficulty with resting began. 
A) Document the sleep patterns and complaint in the patient's chart. 
B) Tell the patient you are just focused on the leg right now. 
C) Explain that a more thorough assessment will be needed next shift. 
D) Ask the patient about his usual sleep patterns and when the difficulty with resting began.

Question 10

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.How should the nurse first revise the plan of care?

Accepted Answer

A) Asking physiotherapy to assist the patient because of the new injuries. 
B) Disregarding all previous diagnoses and establishing a new plan of care. 
C) Reassessing the patient. 
D) Setting new priorities for the patient. 
A) Asking physiotherapy to assist the patient because of the new injuries. 
B) Disregarding all previous diagnoses and establishing a new plan of care. 
C) Reassessing the patient. 
D) Setting new priorities for the patient.

Question 11

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

Accepted Answer

A) The patient will ambulate in hallways. 
B) The nurse will administer pain medication every 4 hours to keep the patient free from discomfort. 
C) The nurse will monitor the patient's heart rhythm continuously this shift. 
D) The patient will feed self at all mealtimes today without complaints of shortness of breath. 
A) The patient will ambulate in hallways. 
B) The nurse will administer pain medication every 4 hours to keep the patient free from discomfort. 
C) The nurse will monitor the patient's heart rhythm continuously this shift. 
D) The patient will feed self at all mealtimes today without complaints of shortness of breath.

Question 12

After reviewing the interview process and objectives during a patient-centred interview,what will the nurse do?

Accepted Answer

A) Begin by introducing himself or herself. 
B) Document a nursing health history. 
C) Explain that the interview will be over in a few more minutes. 
D) Tell the patient that he'll be back to administer medications in 1 hour. 
A) Begin by introducing himself or herself. 
B) Document a nursing health history. 
C) Explain that the interview will be over in a few more minutes. 
D) Tell the patient that he'll be back to administer medications in 1 hour.

Question 13

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?

Accepted Answer

A) The nursing student is making eye contact with the patient. 
B) The nursing student is speaking only to the patient's daughter. 
C) The nursing student nods periodically while the patient is speaking. 
D) The nursing student leans forward while talking with the patient. 
A) The nursing student is making eye contact with the patient. 
B) The nursing student is speaking only to the patient's daughter. 
C) The nursing student nods periodically while the patient is speaking. 
D) The nursing student leans forward while talking with the patient.

Question 14

What is the purpose and distinction of using a concept map when a plan of care is implemented?

Accepted Answer

A) Quality assurance in the health care facility. 
B) Multidisciplinary communication. 
C) Provision of a standardized format for patient problems. 
D) Identification of the relation of patient problems and interventions. 
A) Quality assurance in the health care facility. 
B) Multidisciplinary communication. 
C) Provision of a standardized format for patient problems. 
D) Identification of the relation of patient problems and interventions.

Question 15

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

Accepted Answer

A) Leave the room and place the patient in isolation. 
B) Ask the patient to describe the type of reaction. 
C) Proceed to the termination phase of the interview. 
D) Document the latex allergy on the medication administration record. 
A) Leave the room and place the patient in isolation. 
B) Ask the patient to describe the type of reaction. 
C) Proceed to the termination phase of the interview. 
D) Document the latex allergy on the medication administration record.

Question 16

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

Accepted Answer

A) Reviewing the current literature to determine evidence-informed nursing actions. 
B) Orders for diagnostic and laboratory tests. 
C) Physical examination. 
D) Anticipated medications to be ordered. 
A) Reviewing the current literature to determine evidence-informed nursing actions. 
B) Orders for diagnostic and laboratory tests. 
C) Physical examination. 
D) Anticipated medications to be ordered.

Question 17

Components of a nursing health history include

Accepted Answer

A) Current treatment orders. 
B) Nurse's concerns. 
C) Nurse's goals for the patient. 
D) Patient expectations. 
A) Current treatment orders. 
B) Nurse's concerns. 
C) Nurse's goals for the patient. 
D) Patient expectations.

Question 18

When evaluating a plan of care,the nurse reviews the goals for the patient.Which goal statement is realistic for a patient with a pelvic fracture on bed rest?

Accepted Answer

A) The patient will increase mobility by ambulating in the hallway two times this shift. 
B) The patient will increase mobility by turning side to back to side with assistance every 2 hours. 
C) The patient will increase mobility by using the walker correctly to ambulate to the bathroom as needed. 
D) The patient will increase mobility by using a sliding board correctly to transfer to the bedside commode as needed. 
A) The patient will increase mobility by ambulating in the hallway two times this shift. 
B) The patient will increase mobility by turning side to back to side with assistance every 2 hours. 
C) The patient will increase mobility by using the walker correctly to ambulate to the bathroom as needed. 
D) The patient will increase mobility by using a sliding board correctly to transfer to the bedside commode as needed.

Question 19

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?

Accepted Answer

A) Patient will have one soft,formed bowel movement by end of shift. 
B) Patient will not take any pain medications this shift. 
C) Patient will walk unassisted to bathroom by the end of shift. 
D) Patient will not take laxatives or stool softeners this shift. 
A) Patient will have one soft,formed bowel movement by end of shift. 
B) Patient will not take any pain medications this shift. 
C) Patient will walk unassisted to bathroom by the end of shift. 
D) Patient will not take laxatives or stool softeners this shift.

Question 20

The following statements are part of a patient's nursing care plan.Which of the following statements represents an expected outcome?

Accepted Answer

A) The patient will verbalize a decreased pain level less than 3 on a 0-to-10 scale by the end of this shift. 
B) The patient will demonstrate increased mobility in 2 days. 
C) The patient will demonstrate increased tolerance of activity over the next month. 
D) The patient will understand needed dietary changes by discharge. 
A) The patient will verbalize a decreased pain level less than 3 on a 0-to-10 scale by the end of this shift. 
B) The patient will demonstrate increased mobility in 2 days. 
C) The patient will demonstrate increased tolerance of activity over the next month. 
D) The patient will understand needed dietary changes by discharge.

Exam 13: Nursing Assessment, diagnosis, and Planning

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

A patient verbalizes a low pain level of 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?

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

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

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

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

Subjective data include which of the following?

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

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.How should the nurse first revise the plan of care?

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

After reviewing the interview process and objectives during a patient-centred interview,what will the nurse do?

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?

What is the purpose and distinction of using a concept map when a plan of care is implemented?

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

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

Components of a nursing health history include

When evaluating a plan of care,the nurse reviews the goals for the patient.Which goal statement is realistic for a patient with a pelvic fracture on bed rest?

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?

The following statements are part of a patient's nursing care plan.Which of the following statements represents an expected outcome?

Health and Wellness

The Canadian Health Care Delivery System

The Development of Nursing in Canada

Community Health Nursing Practice

Theoretical Foundations of Nursing Practice

Evidence-Informed Practice

Nursing Values and Ethics

Legal Implications in Nursing Practice

Global Health

Indigenous Health

Nursing Leadership, management, and Collaborative Practice

Critical Thinking in Nursing Practice

Implementing and Evaluating Nursing Care

Documenting and Reporting

Nursing Informatics and Canadian Nursing Practice

Communication and Relational Practice

Patient-Centred Care: Interprofessional Collaborative Practice

Family Nursing

Patient Education

Developmental Theories

Conception Through Adolescence

Young to Middle Adulthood

Older Persons

The Experience of Loss, death, and Grief

Self-Concept

Sexuality

Spirituality in Health and Health Care

Stress and Adaptation

Vital Signs

Pain Assessment and Management

Health Assessment and Physical Examination

Infection Control

Medication Administration

Complementary and Alternative Approaches in Health Care

Activity and Exercise

Quality and Patient Safety

Hygiene

Cardiopulmonary Functioning and Oxygenation

Fluid, electrolyte, and Acid-base Balances

Sleep

Nutrition

Urinary Elimination

Bowel Elimination

Mobility and Immobility

Skin Integrity and Wound Care

Sensory Alterations

Care of Surgical Patients

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