Exam 9: Nursing Process

A patient is suffering from shortness of breath.How should the nurse write the expected outcome for this patient?

The nurse is admitting a patient to the unit and asks the patient about the health history.The nurse is engaged in which component of the nursing process?

A patient states,"I'm burning up,and I have a fever." The nurse takes the patient's temperature,observes the skin for flushing,and feels the skin temperature.This is an example of __________ subjective data.

A nurse is collecting data during the assessment of a patient.During the assessment,the nurse collects both subjective and objective data.Which information should the nurse consider as subjective data?

Upon assessment,the nurse finds that a patient has a heart rate of 66 beats per minute,a respiratory rate of 12 breaths per minute,and a blood pressure of 120/80 mm Hg.The nurse obtained which type of data?

A 67-year-old male patient of French heritage is admitted to the hospital.The patient is interviewed by a nurse from a Korean family.The nurse did not make eye contact with the patient while conducting the interview.This disturbed the patient because the patient thought that the nurse might be trying to hide something.Which factor most likely influenced the behavior of the nurse and patient?

A nurse is interviewing a patient being admitted to the hospital for surgery.During the interview,the nurse introduces self and explains that will be gathering some information.The nurse is in which phase of the interview?

A nurse is writing a care plan for a newly admitted patient.Which outcome statement did the nurse correctly write?

A mother of five children is admitted to the hospital for abdominal pain.The nurse asks a series of questions before performing a physical assessment.The patient answers the questions.When asking the patient some other questions,the patient's spouse starts to answer.As the admission process progresses and the nurse gathers subjective data,the nurse requests that the patient answer the next questions.What is the rationale for the nurse's behavior?

A student nurse is responsible for assessing a patient,who is abrupt and requests that the assessment be done later by a nurse.As the student nurse charts the interaction,which statement is the best way to document what happened?

Which action by the nurse is the final step in a complete assessment?

A nurse is evaluating care for a patient.Which action should the nurse take?

When admitting a patient to the hospital,the nurse asks if has problems eating since the patient had a stroke.The patient denies any problems and states that does not require assistance.After lunch,the nurse notes that the patient has not eaten most of the food and has spilled much of the food.These cues lead the nurse to believe that the patient is not functioning at the level indicated upon admission.The nurse is using which type of information to make this deduction?

A patient is admitted to the hospital after a motorcycle accident.The nurse in the emergency room is assessing vital signs,general appearance and behavior,and performing a head-to-toe examination of all body systems.What is the nurse doing?

A postoperative patient has denied the need for pain medication.The nurse has noted that the patient describes the pain as a "1" on a 0 to 10 scale.The nurse also notes that the patient grimaces when he or she changes position and guards the incision.The nurse believes that the patient is experiencing pain based on the information gathered in the assessment.What is this phenomenon known as?

As a nurse is obtaining a health history from a patient,the nurse uses comments such as "go on." Which technique is the nurse using?

A patient with a history of seizures is being admitted to the hospital after a grand mal seizure took place at a shopping mall.The patient's spouse accompanied the patient to the hospital and is being interviewed by the nurse.Which question should the nurse ask to quickly focus on the patient's symptoms?

A nurse is teaching the staff about the phases of the interview process.Which information should the nurse include in the teaching session?

The nurse is beginning an assessment of a newly admitted patient.What are some recommended comprehensive assessment approaches the nurses can use? (Select all that apply.)

A nurse is collecting data on a patient who is being admitted into hospice care.The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained.The nurse is currently involved in which step of the nursing process?