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Insights into the critical role of effective communication and collaboration among members of the healthcare team. It highlights the importance of organizing nurses' thought processes, facilitating communication, and addressing patient needs as the primary focus of nursing interventions. Various aspects of patient assessment, goal setting, care planning, and quality improvement, emphasizing the need for a patient-centered approach and cultural competence. By studying this document, students can gain a deeper understanding of the multifaceted nature of healthcare teamwork, the nurse's responsibilities in coordinating care, and the strategies for enhancing patient outcomes through collaborative practice.
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What is the purpose of the nursing process? a. Providing patient-centered care b. Identifying members of the health care team c. Organizing the ways nurses think about patient care d. Facilitating communication among members of the health care team - Correct Answer c. organizing the ways nurses think about patient care A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. Family history of diabetes b. Medications the patient is taking c. Operations the patient has had in the past d. Severity and duration of the nausea and vomiting - Correct Answer d. Severity and duration of the nausea and vomiting An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient? a. Family member b. Physician c. Another nurse d. Patient - Correct Answer d. Patient What is the primary purpose of the nursing diagnosis? a. Resolving patient confusion b. Communicating patient needs c. Meeting accreditation requirements d. Articulating the nursing scope of practice - Correct Answer b. Communicating patient needs On what premise is a nursing diagnosis identified for a patient? a. First impressions b. Nursing intuition c. Clustered data d. Medical diagnoses - Correct Answer c. Clustered data Which statement is an appropriately written short-term goal? a. Patient will walk to the bathroom independently without falling within 2 days after surgery. b. Nurse will watch patient demonstrate proper insulin injection technique each morning. c. Patient's spouse will express satisfaction with patient's progress before discharge.
d. Patient's incision will be well approximated each time it is assessed by the nurse. - Correct Answer a. Patient will walk to the bathroom independently without falling within 2 days after surgery. What should be the primary focus for nursing interventions? a. Patient needs b. Nurse concerns c. Physician priorities d. Patient's family requests - Correct Answer a. Patient needs Which nursing action is critical before delegating interventions to another member of the health care team? a. Locate all members of the health care team. b. Notify the physician of potential complications. c. Know the scope of practice for the other team member. d. Call a meeting of the health care team to determine the needs of the patient. - Correct Answer c. Know the scope of practice for the other team member. A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? A. Identify reasons the patient is unable to sleep. b. Request medication to help the patient sleep. c. Tell the patient that sleep will come with relaxation. d. Notify the physician that the patient is restless and anxious. - Correct Answer a. Identify reasons the patient is unable to sleep. What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. Consult the surgeon to see if the clinical pathway is being followed. b. Discontinue the plan of care, because the patient has met the established goal. c. Monitor patient urine output to evaluate the need for the current plan of care. d. Notify the patient that the goal has been attained and no further intervention is needed. - Correct Answer c. Monitor patient urine output to evaluate the need for the current plan of care. Which action by a patient marks the beginning of the physical assessment process? a. Redressing after a physical examination b. Breathing normally during auscultation c. Greeting the nurse in the examination room d. Sharing work environment information - Correct Answer c. greeting the nurse in the examination room Which factors should be taken into consideration by the nurse before and during a patient interview? (Select all that apply.) a. Distance between the chairs in which the nurse and patient are sitting b. Traditional treatments typically used by the patient to treat disease
c. Gender preference for primary care providers d. Physical condition of the patient e. Music preference of the patient - Correct Answer a. Distance between the chairs in which the nurse and patient are sitting b. Traditional treatments typically used by the patient to treat disease c. Gender preference for primary care providers d. Physical condition of the patient Which action by the nurse is most appropriate during the orientation phase of the patient interview? a. Always position patients in a comfortable reclined position to ensure their comfort during questioning. b. Ask which name a patient prefers to be called during care to show respect and build trust. c. Quickly conduct a review of systems to determine the need for a complete or focused assessment. d. Begin with questions about intimacy and sexuality to address sensitive issues first. - Correct Answer b. Ask which name a patient prefers to be called during care to show respect and build trust. Which activity by the nurse best demonstrates part of the working phase of a patient interview? a. Summarizing previously discussed key topics b. Including selected family members in care planning c. Transferring care responsibilities to the home health nurse d. Verifying the name by which a patient prefers to be addressed - Correct Answer b. including selected family members in care planning Which entry in a patient's electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data? a. Complaining of chest pain b. Apical pulse 110 c. Comatose d. Difficulty swallowing - Correct Answer c. Comatose Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process? a. "What do you do for a living? Can you describe your work environment?" b. "Is there a family history of heart disease, cancer, high blood pressure, or stroke?" c. "When was your last annual physical? What immunizations did you receive at that time?" d. "Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?" - Correct Answer d. "Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?" Which cue by a patient can be validated by laboratory and diagnostic test results?
a. Deeply sighing with fatigue b. Bilateral crackles in the lungs c. Oxygen saturation of 98% on room air d. 2+ pitting edema of the ankles and feet - Correct Answer a. deeply sighing with fatigue A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively? a. Body systems model b. Physical assessment model c. Head-to-toe assessment model d. Functional health patterns model - Correct Answer d. Functional health patterns model When initiating a physical examination, which action should the nurse take first? a. Review of the patient's prior medical records b. Gather admission health history forms c. Assess the patient's vital signs d. Perform light and deep palpation for fluid - Correct Answer c. Assess the patient's vital signs If the nurse discovers that a patient's right elbow is swollen and painful during a physical examination, which action should the nurse take next? a. Apply ice to decrease swelling and reduce pain b. Percuss the area to determine the presence of fluid c. Perform passive range of motion to promote flexibility d. Inspect the patient's left elbow to compare its appearance - Correct Answer d. Inspect the patient's left elbow to compare its appearance What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I? a. Insurance documentation b. Professional autonomy c. Role delineation d. Patient safety - Correct Answer d. Patient safety Which nursing diagnosis is appropriately written? (Select all that apply.) a. Risk for Infection related to elevated temperature and white blood count b. Readiness for Enhanced Relationship as evidenced by mutual respect verbalized by spouses and expressed desire for improved communication c. Noncompliance related to inability to access care as evidenced by failure to keep appointments, homebound status d. Risk for Bleeding with the risk factor of prolonged clotting time e. Chronic Pain related to osteoarthritis as manifested by verbalized postoperative discomfort. - Correct Answer b. Readiness for Enhanced Relationship as evidenced by
mutual respect verbalized by spouses and expressed desire for improved communication c. Noncompliance related to inability to access care as evidenced by failure to keep appointments, homebound status d. Risk for Bleeding with the risk factor of prolonged clotting time Which phrase best represents a related factor in an actual nursing diagnosis? a. Unsteady gait requiring the assistance of two people b. Redness and swelling around the incision site c. Ineffective adaptation to recent loss d. Patient complaint of restlessness - Correct Answer c. Ineffective adaptation to recent loss Which action does the nurse need to take before determining the type(s) of nursing diagnoses that are applicable to a patient? (Select all that apply.) a. Thoroughly review the patient's medical history b. Analyze the nursing assessment data to determine whether information is complete c. Outline an individualized plan of care to address each concern d. Consider potential complications to which the patient is susceptible e. Evaluate how the patient has responded to treatment - Correct Answer a. thoroughly review the patient's medical history b. Analyze the nursing assessment data to determine whether information is complete d. Consider potential complications to which the patient is susceptible What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis? a. Defining characteristics are not part of a risk diagnosis. b. There is no cause and effect relationship established. c. Defining characteristics are subjective in a risk diagnosis. d. There are no nursing interventions prescribed with a risk diagnosis. - Correct Answer a. Defining characteristics are not part of a risk diagnosis. What is the most important action for a nurse take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy? a. Share concerns with the nurse manager on the nursing unit b. Offer alternative care for a patient and family members c. Discuss how to address patient needs with physicians d. Provide evidence-based research to support nursing care - Correct Answer d. Provide evidence-based research to support nursing care What is the most significant problem that may result from improperly written nursing diagnostic statements? a. Lack of direction for formulating patient plans of care b. Omission of physician or primary care provider orders c. Combining of two unrelated patient concerns
d. Increased team collaboration needs - Correct Answer a. Lack of direction for formulating patient plans of care Which statement best describes the relationship of medical diagnoses and nursing diagnoses? a. Medical diagnoses are imbedded in nursing diagnoses. b. Nursing diagnoses are derived from medical diagnoses. c. Medical diagnoses are not relevant to nursing diagnoses. d. Medical diagnoses may be interrelated to nursing diagnoses. - Correct Answer d. Medical diagnoses may be interrelated to nursing diagnoses. A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take? a. Resume all interventions for previously identified nursing diagnoses. b. Perform the steps of the nursing process related to the patient's current condition. c. Seek physician input related to updating the nursing diagnosis statements. d. Evaluate the success of the acute care plan for management of the cardiac arrest. - Correct Answer b. Perform the steps of the nursing process related to the patient's current condition. What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.) a. Denies any difficulty falling asleep b. Elevated pulse rate auscultated at 140 BPM c. Continuous foot tapping throughout intake interview d. Demonstrates how to give insulin self-injection without hesitation e. Patient states, "I feel nervous all the time, especially when I am alone." - Correct Answer b. Elevated pulse rate auscultated at 140 BPM c. Continuous foot tapping throughout intake interview e. Patient states, "I feel nervous all the time, especially when I am alone." Which action would the nurse undertake first when beginning to formulate a patient's plan of care? a. List possible treatment options b. Identify realistic outcome indicators c. Consult with health care team members d. Rank patient concerns from assessment data - Correct Answer d. Rank patient concerns from assessment data Which resource is most helpful when prioritizing identified nursing diagnoses? a. Nursing Interventions Classification (NIC) b. Gordon's functional health patterns c. Maslow's hierarchy of needs d. Nursing Outcomes Classification (NOC) - Correct Answer c. Maslow's hierarchy of needs
If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care? a. Fatigue b. Acute Pain c. Knowledge Deficit d. Body Image Disturbance - Correct Answer b. Acute Pain Which statement illustrates a characteristic of goals within the care planning process? a. Goals are vague objectives communicating expectations for improvement. b. Short-term goals need not be measurable, unlike long-term goals. c. Goal attainment can be measured by identifying nursing interventions. d. Long-term goals are helpful in judging a patient's progress. - Correct Answer d. Long- term goals are helpful in judging a patient's progress. Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery? a. Nurse will encourage use of sterile technique during each dressing change. b. Patient's white blood count will remain within normal range throughout hospitalization. c. Patient's visitors will be instructed in proper hand washing before direct interaction with patient. d. Patient will understand the importance of cleaning around the incision with a clean cloth during bathing. - Correct Answer b. Patient's white blood count will remain within normal range throughout hospitalization. If the nurse chooses the Nursing Outcome Classification (NOC), Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.) a. Expressed desire to eat b. Report that food smells good c. Use of relaxation techniques before meals d. Preparation of home-cooked meals for self and family e. Uses nutritional information on labels to guide selections - Correct Answer a. Expressed desire to eat b. Report that food smells good d. Preparation of home-cooked meals for self and family Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult? a. Providing a written copy of care options to the patient and family b. Collaborating with the patient's social worker to determine resources c. Listening to the patient's concerns and beliefs about proposed treatment d. Engaging the patient's family, friends, or care providers in conversation - Correct Answer c. listening to the patient's concerns and beliefs about proposed treatment
Which intervention can the nurse initiate independently while providing patient care? (Select all that apply.) a. Ordering a blood transfusion b. Auscultating lung sounds c. Monitoring skin integrity d. Applying heel protectors e. Adjusting antibiotic dosages - Correct Answer b. Auscultating lung sounds c. Monitoring skin integrity d. Applying heel protectors The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider? a. Elevating the head of the patient's bed b. Administering oxygen by nasal cannula c. Assessing the patient's oxygen saturation d. Evaluating the patient's peripheral circulation - Correct Answer b. administering oxygen by nasal cannula Which situation indicates the greatest need for collaborative interventions provided by several health care team members? a. Hospice referral b. Physical assessment c. Activities of daily living d. Health history interview - Correct Answer a. Hospice referral What should the nurse consider before implementation of all nursing interventions? (Select all that apply.) a. Potential communication barriers b. Diverse cultural practices c. Scope of nursing practice d. Functional status of the patient e. Time of most recent shift change - Correct Answer a. Potential communication barriers b. Diverse cultural practices c. Scope of nursing practice d. Functional status of the patient Which intervention would be most important for the nurse to include in a patient's care plan if the patient is unable to complete activities of daily living without becoming fatigued? a. Instruct the patient to shower and shave simultaneously b. Discourage the patient from bathing while hospitalized c. Encourage the patient to rest between bathing activities d. Ask the patient's spouse to assist with all bathing - Correct Answer c. Encourage the patient to rest between bathing activities
Which nursing intervention is most important to complete before giving medication to a patient? a. Provide water to aid in the patient's ability to swallow the medication. b. Double-check the patient's allergies before giving the drug. c. Ask the patient to verify having taken the medication before. d. Place the patient in a side-lying position to prevent aspiration. - Correct Answer b. Double-check the patient's allergies before giving the drug. Which direct-care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer? a. Reassessing for changes in the patient's physical condition b. Teaching the patient various methods of stress reduction c. Referring the patient for music and massage therapy d. Encouraging the patient to explore options for care - Correct Answer d. encouraging the patient to explore options for care What should be taken into consideration by the nurse when deciding on interventions to include in a patient's plan of care? (Select all that apply.) a. Patient's treatment preferences b. Cultural and ethnic influences c. Professional level of expertise d. Current evidence-based research e. Convenience to the nursing staff - Correct Answer a. Patient's treatment preferences b. Cultural and ethnic influences c. Professional level of expertise d. Current evidence-based research Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention? a. Ambulating a patient with ataxia and new right sided paresthesia b. Feeding a patient with cerebral palsy who recently aspirated c. Transporting a patient to the hospital entrance for discharge d. Administering prescribed programmed medications - Correct Answer c. transporting a patient to the hospital entrance for discharge Which action is a part of the evaluation step in the nursing process? (Select all that apply.) a. Recognizing the need for modifications to the care plan B. Documenting performed nursing interventions c. Determining if nursing interventions were completed d. Reviewing whether a patient met their short-term goal e. Identifying realistic outcomes with patient input - Correct Answer a. recognizing the need for modifications to the care plan d. Reviewing whether a patient met their short-term goal
Which action by the day-shift nurse provides objective data that enables the night- shift nurse to complete an evaluation of a patient's short-term goals? a. Encouraging the patient to share observations from the day b. Leaving a message with the charge nurse before shift change c. Documenting patient assessment findings in the patient's chart d. Checking with the pharmacist regarding possible drug interactions - Correct Answer c. Documenting patient assessment findings in the patient's chart Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal, "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)"? a. Goal not met; patient states he is tired. b. Goal not met; patient ambulated three times in room. c. Goal met; patient ambulated three times in the hallway. d. Goal met; patient ambulated three times in the hallway without SOB. - Correct Answer d. Goal met; patient ambulated three times in the hallway without SOB. What is the primary purpose of quality improvement? a. Recognizing the need to discipline employees violating policies b. Preventing patient injury that may contributor to the death of others c. Increasing institutional profits to support further scientific research d. Enhancing current practices to improve patient outcomes and care - Correct Answer d. Enhancing current practices to improve patient outcomes and care Which statement best serves as a guide for nurses seeking to learn more about ethnicity? a. Ethnicity, like culture, generally is based on genetics. b. A patient's ethnic background is determined by skin color. c. Ethnicity is based on cultural similarities and differences in a society. d. Culture and socialization are unrelated to the concept of ethnic origin. - Correct Answer c. Ethnicity is based on cultural similarities and differences in a society. Which action taken by a nurse would reflect application of an appropriate generalization in a patient care setting? a. Assigning same-gender nurses to all patients admitted to the unit b. Sharing with unlicensed assistive personnel that typically Muslim patients do not eat pork c. Telling the radiology technician that every Latino family is late for appointments d. Assuming that Asians share financial responsibility for medical bills - Correct Answer b. sharing with unlicensed assistive personnel that typically Muslim patients do not eat pork Which statement(s) reflect/s the practice of transcultural nursing? (Select all that apply.) a. May be considered a general and specialty practice area b. Focuses on the world view rather than patient needs c. Challenges traditional ethnocentric nursing practice
d. Aims to identify individual patient care preferences e. Focuses patient care on the nurse's cultural norms - Correct Answer a. May be considered a general and specialty practice area c. Challenges traditional ethnocentric nursing practice d. Aims to identify individual patient care preferences Which of the following questions is/are appropriate to ask during a transcultural assessment? (Select all that apply.) a. How do you act when you are angry? b. What is your role in your extended family? c. Why do you continue to speak German at home? d. When communicating with friends, how close do you stand? e. What is the purpose of not preparing beef with milk products? - Correct Answer a. How do you act when you are angry? b. What is your role in your extended family? d. When communicating with friends, how close do you stand? How best can a nurse evaluate goal attainment for a patient with a culturally diverse background? a. Assume that gender roles will be a challenge to overcome regardless of the patient's ethnicity. b. Base decisions on feedback from the patient and the nurse's professional judgment. c. Collaborate with future community care providers to determine patient strengths. d. Seek input from members of the patient's support system to avoid biased patient responses. - Correct Answer b. Base decisions on feedback from the patient and the nurse's professional judgment. What aspect of culture is a full-time employed granddaughter of an elderly Asian female exhibiting if she asks the social worker to place her grandmother in an extended-care facility against the wishes of her parents? a. System change b. Gender role c. Cultural norms d. Shared attributes - Correct Answer a. System change Culturally competent care would encourage which action by a patient's family? a. Asking the family's spiritual advisor to visit the patient b. Speaking English to everyone involved in patient care c. Adhering to highly publicized restrictive unit visiting hours d. Limiting food consumption to items provided by the cafeteria - Correct Answer a. asking the family's spiritual advisor to visit the patient If a patient's primary language differs from that of the health care professionals providing care, which action is most appropriate for the nurse to take? a. Use colorful pictures, white boards, and gestures to communicate all important information.
b. Recognize that continuous affirmative answers by the patient require verification of understanding. c. Arrange for a professional language translator to sit with the patient throughout the hospitalization. d. Decrease interaction with the patient and family to avoid making them uncomfortable for not understanding. - Correct Answer b. Recognize that continuous affirmative answers by the patient require verification of understanding. Which nursing diagnosis is most appropriate for a young Middle Eastern immigrant who expresses concern for the safety of his family members who were unable to relocate with him out of a war zone? A. Risk for Spiritual Distress b. Impaired Role Performance C. Interrupted Family Processes d. Ineffective Coping - Correct Answer c. Interrupted Family Processes What is the best method for the nurse to ensure that a Croatian patient's nutritional needs are met during hospitalization? a. Preorder a diet that is consistent with the typical Croatian patient's dietary preferences. b. Ask a Croatian co-worker for ideas on what would be best to order for the patient's meals. c. Request that a variety of dietary entrees be provided to the patient to provide options. d. Check with the patient on admission to determine dietary limitations and preferences.
The nurse has been caring for a patient who just died. The patient's daughter is crying uncontrollably, saying, "She was my best friend. I thought she would make it! I don't know what I am going to do." What is the nurse's best response? a. Express sympathy, and ask if she would like to talk with a chaplain. b. Give the daughter time to cry in her mother's room alone. c. Ask the daughter if her father is still living. d. Inquire if the daughter would like to pray. - Correct Answer a. Express sympathy, and ask if she would like to talk with a chaplain. A nurse assigned to the neonatal intensive care unit (NICU) has spent most of a day working with a critically ill infant, with the mother standing by. The infant experiences a cardiac arrest and does not survive. The mother spends an hour crying and holding the baby, saying good-bye. Which spiritual care intervention(s) is/are most appropriate for the nurse to implement? (Select all that apply.) a. If desired, briefly hold the baby to say good-bye after the mother leaves. b. Follow procedures to prepare the body for transport to the morgue. c. Visit the mother the next day to see how she is doing. d. Call the family spiritual adviser or the chaplain. e. Ask the mother if you could call a family member or friend to be with her. - Correct Answer a. If desired, briefly hold the baby to say good-bye after the mother leaves. d. Call the family spiritual adviser or the chaplain. e. Ask the mother if you could call a family member or friend to be with her. Which statement by a patient best illustrates reflection on a spiritual need? a. "My husband told me what to do about this situation, and I'm sure he's right." b. "There is little I can do now to change my circumstances. I just need to adapt." c. "I need to think a little more about how I feel about undergoing this treatment." d. "Whatever the physician wants to do is fine. I don't have much of an option." - Correct Answer c. "I need to think a little more about how I feel about undergoing this treatment." What is the most important aspect of providing spiritual care in nursing practice? a. Call a chaplain. b. Complete the FICA spiritual assessment and refer as needed. c. Recognize situations and patient behaviors indicating a spiritual need. d. Spend some time in self-reflection. - Correct Answer c. Recognize situations and patient behaviors indicating a spiritual need. When caring for patients who are Jewish, how best can the nurse address their religious needs? a. Order a kosher diet. b. Allow time for prayer before each meal. c. Ask about religious holidays, particularly religious practices around the Sabbath. d. Ask about religious practices affecting care. - Correct Answer d. Ask about religious practices affecting care
The nurse is caring for a 45-year-old woman who is a breast cancer survivor. What activity associated with her cancer experience will promote this patient's spiritual well- being? a. Attending church every week B. Ensuring she follows her medication regimen c. Genetic testing on family members d. Speaking about her cancer experience to increase breast cancer awareness - Correct Answer d. speaking about her cancer experience to increase breast cancer awareness The nurse is caring for a Catholic patient who is going to surgery tomorrow. The patient states that she is afraid and asks the nurse to pray with her, although the nurse is not religious. What is the most appropriate response by the nurse? a. "I am not confident praying, but I will think about you tomorrow." b. "I need to take care of other patients right now, but I will be back." c. "I am uncomfortable praying. May I call the chaplain for you?" d. "I don't do that. Nurses are not allowed to do that at our hospital." - Correct Answer c. "I am uncomfortable praying. May I call the chaplain for you?" How do people who participate in organized religion differ from nonreligious people? a. Religious people are healthier than spiritual people. b. Religious people are more spiritual than nonreligious people. c. Religious people express their spirituality through faith traditions. d. Religious people have spiritual practices, whereas nonreligious people do not have spiritual practices. - Correct Answer c. Religious people express their spirituality through faith traditions.