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NUR 514 TOPIC 8 ASSIGNMENT REVIEW AND
SOLUTIONS 2026
โ SBAR. Answer: consistent, clear, structured, and easy-to-use method of communication between health care personnel Situation (your name, where from, pt, room #, why calling) Background (age, PERTINENT info) Assessment (current vitals, assess. findings, what you think problem is) Recommendations (what action? change in treatment? more labs? does provider want a call back with updates?) โ Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? A. Use the previous, less restrictive policy conscientiously B. Express immediate disagreement with the new policy
C. Ask for the rationale behind the new policy D. Obey the policy but continue to voice disapproval of it to co- workers. Answer: C. Ask for the rationale behind the new policy Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed change and understand its purpose. Options 1, 2, and 4 represent unprofessional behavior. Option 1 also places a client's safety at risk. โ Safety Risks by Developmental Stage. Answer: Children younger than 5 years of age: home accidents that result in severe injury or death School-aged child: risk for injury at home, school, while traveling to and from school Adolescent: risk for injury from automobile accidents, suicide, and substance abuse Adult: frequently associated with lifestyle habits Older patient: directly related to physiological changes on the aging process (falls!)
D. Children need to learn to swim even if they do not have a pool.. Answer: B. โ The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis. Answer: B. Reexamine the nursing orders Rationale: The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome. โ A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include:
A. Raise all four side rails when darkness falls. B. Use an electronic bed monitoring device. C. Place the patient in a room close to the nursing station. D. Use a loose-fitting vest-type jacket restraint.. Answer: B. โ In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction B. Instruct the client to make dietary changes by reducing sodium intake C. Include the client and family when setting goals and formulating the plan of care D. Assess past compliance to medication regimens. Answer: C. Include the client and family when setting goals and formulating the plan of care Rationale: In developing a plan of care, nurses engage in a partnership with the client and family. Nurses do not plan care for clients; instead they plan care with clients and families. Assessment (option 4), goal setting (option 1), and interventions (option 2) will be most accurate and effective when carried out in partnership with the client and family. The other options represent other actions to take, but they will have less overall effectiveness if the client and family are not part of the plan.
โ adverse events that should never occur in a health care setting. Answer: never event โ The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source B. Subjective data from a secondary source C. Objective data from a primary source D. Objective data from a secondary source. Answer: A. Subjective data from a primary source Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? โ A nurse discovers an electrical fire in a patient's room. Which action should the nurse take first? Turn off the oxygen to the unit. Evacuate any patients/visitors in immediate danger. Close all doors and windows.
Use the nearest fire extinguisher to put the fire out.. Answer: Evacuate any patients/visitors in immediate danger โ The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein intake C. Risk for impaired skin integrity related to malnutrition D. Impaired nutrition related to current illness. Answer: C. Risk for impaired skin integrity related to malnutrition Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or less than body requirements) and is therefore incomplete. It also does not provide direction for development of goals and interventions. โ A young mother asks the nurse in the outpatient clinic what causes toddlers to often have accidents. Which of the following
โ What is the proper order for applying a wrist restraint?
- Pad the skin overlying the wrist.
- Insert two fingers under secured restraint to be sure that it is not too tight.
- Be sure that patient is comfortable and in correct anatomical alignment.
- Secure restraint straps to bed frame with quick-release buckle.
- Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly.. Answer: 3,1,5,2, โ Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge
E. Client will be medicated every 4 hours by the nurse. Answer: C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal. โ Maslow's Hierarchy of Needs. Answer: (level 1) Physiological Needs: oxygen, fluids, nutrition, body temperature, elimination, shelter, sex (level 2) Safety and Security (level 3) Relationships, Love and Affection (level 4) Self Esteem (level 5) Self Actualization โ The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight and age. The nurse should take which of the following actions?
โ Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)? A. Taking vital signs of clients on the nursing unit B. Assisting the physician with an invasive procedure C. Adjusting the rate on an infusion pump D. Evaluating achievement of client outcome goals. Answer: A. Taking vital signs of clients on the nursing unit Rationale: Part of the professional nurse's role is to delegate responsibility for activities while maintaining accountability. The nurse must match the needs of the client with the skills and knowledge of UAPs. Certain skills and activities, such as those in options 2, 3, and 4, are not within the legal scope of practice for a UAP. โ Includes all intellectual behaviors and requires thinking. Answer: Cognitive โ In giving a change-of-shift report, which type of client information communicated by the nurse is most appropriate? A. Vital signs are stable
B. Client is pleasant, alert, and oriented to time, place, and person C. The chest x-ray results were negative D. Client voided 250 mL of urine 2 hours after the urinary catheter removal. Answer: D. Client voided 250 mL of urine 2 hours after the urinary catheter removal Rationale: A change-of-shift report should include significant changes (good or bad) in a client's condition. The information should be accurate, concise, clear, and complete. Options 1 is vague and options 2 and 3 are normal data and are therefore of lesser importance to convey in the change-of-shift report. โ Deals with expression of feelings and development of attitudes, opinions, or values. Answer: Affective โ Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A. Diagnosis B. Planning C. Implementation D. Evaluation. Answer: D. Evaluation
Psychomotor deficits. Answer: Barriers of learning โ (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death (2) achieve health equity, eliminate disparities, and improve the health of all groups (3) create social and physical environments that promote good health for all (4) promote quality of life, healthy development, and healthy behaviors across all life stages. Answer: Healthy People 2020 โ precedes disease or dysfunction and is applied to patients considered physically and emotionally healthy Examples: vaccinations, hearing protection in occupational settings. Answer: Primary prevention โ includes screening techniques and treating early stages of disease to limit disability by averting or delaying the consequences of advanced disease focuses on individuals who are experiencing health problems or illnesses and are at risk for developing complications or worsening conditions.. Answer: Secondary prevention
โ minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration Activities are directed at rehabilitation rather than diagnosis and treatment.. Answer: Tertiary prevention โ Steps of the Nursing Process. Answer: 1. Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation โ A nursing diagnosis is the same as a medical diagnosis. (T/F). Answer: FALSE: The nursing diagnosis is the basis for the care plan and will only refer to the medical diagnosis if the problem in the care plan is "secondary to (medical diagnosis.)" โ When writing a three-part nursing diagnosis, the acronym PES stands for. Answer: Problem (ex. impaired physical mobility, acute pain, impaired memory)
โ Data should be (1, 2, 3). Answer: Collected Validated Clustered โ Genetic and physiological risk factors include those related to. Answer: heredity, genetic predisposition to an illness, or those that involve the physical functioning of the body. (Certain physical conditions such as being pregnant or overweight place increased stress on physiological systems (e.g., the circulatory system), increasing susceptibility to illness in these areas. A person with a family history of diabetes mellitus is at risk for developing the disease later in life because of a hereditary and genetic predisposition to the disease.) โ A patient comes to the local health clinic and states: "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the patient through the stages of change for exercise?. Answer: "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" The patient's response indicates she is in the contemplative state, possibly intending to make a behavior change within the next 6
months. The nurse's statement reinforces the behavior and provides a specific goal for the patient to begin her walking plan. โ External factors impacting health practices include. Answer: family beliefs and economic impact. The way that patients' families use health care services generally affects their health practices. Their perceptions of the seriousness of diseases and their history of preventive care behaviors (or lack of them) influence how patients think about health. Economic variables may affect a patient's level of health by increasing the risk for disease and influencing how or at what point the patient enters the health care system. โ transtheoretical model of change. Answer: precontemplation, contemplation, preparation, action, and maintenance. โ Theory is essential to nursing practice because it:. Answer: Contributes to nursing knowledge. Predicts patient behaviors in situations. Provides a means of assessing patient vital signs. Explains relationships between concepts. โ The components of the nursing metaparadigm include:. Answer: Person, health, environment, and nursing
