TEST BANK Foundations of Maternal-Newborn and Women's
y5 y5 y5 y5 y5 y5
Health Nursing 8th Edition By Sharon Smith Murray
y5 y5 y5 y5 y5 y5 y5 y5
,Chapter 1. Clinical Judgement and the Nursing Process
y5 y5 y5 y5 y5 y5 y5
Foundations of Maternal-Newborn & Women’s Health Nursing, 8th Edition
y5 y5 y5 y5 y5 y5 y5 y5
MULTIPLE CHOICE y5
1. A nurse educator is teaching a group of nursing students about the history of family-centered
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
y5 maternity care. Which statement should the nurse include in the teaching session?
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
a. The Sheppard-Towner Act of 1921 promoted family-centered care.
y5 y5 y5 y5 y5 y5 y5
b. Changes in pharmacologic management of labor prompted family-centered care. y5 y5 y5 y5 y5 y5 y5 y5
c. Demands by physicians for family involvement in childbirth increased the practice y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
of family-centered care.
y5 y5 y5
d. Parental requests that infants be allowed to remain with them rather than in ay5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
nursery initiated the practice of family-centered care.
y5 y5 y5 y5 y5 y5 y5
ANS: y 5 D
As research began to identify the benefits of early, extended parent–infant contact, parents
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
began to insist that the infant remain with them. This gradually developed into the practice of
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
rooming-in and finally to family-centered maternity care. The Sheppard-Towner Act provided
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
funds for state-managed programs for mothers and children but did not promote
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
family-centered care. The changes in pharmacologic management of labor were not a factor in y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
family-centered maternity care. Family-centered care was a request by parents, not physicians.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Application OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Planning MSC: Patient Needs: Health Promotion and Maintenance
y5 y5 y 5 y5 y5 y5 y5 y5
2. Expectant parents ask a prenatal nurse educator, “Which setting for childbirth limits the
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
amount of parent–infant interaction?” Which answer should the nurse provide for these
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
parents in order to assist them in choosing an appropriate birth setting?
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
a. Birth center y5
b. Home birth y5
c. Traditional hospital birth y5 y5
d. Labor, birth, and recovery room y5 y5 y5 y5
ANS: y 5 C
In the traditional hospital setting, the mother may see the infant for only short feeding periods,
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
and the infant is cared for in a separate nursery. Birth centers are set up to allow an increase in
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
parent–infant contact. Home births allow the greatest amount of parent–infant contact. The
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
labor, birth, recovery, and postpartum room setting allows for increased parent–infant contact.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Planning MSC: Patient Needs: Health Promotion and Maintenance
y5 y5 y 5 y5 y5 y5 y5 y5
3. Which statement best describes the advantage of a labor, birth, recovery, and postpartum
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
y5 (LDRP) room? y5
a. The family is in a familiar environment.
y5 y5 y5 y5 y5 y5
b. They are less expensive than traditional hospital rooms.
y5 y5 y5 y5 y5 y5 y5
c. The infant is removed to the nursery to allow the mother to rest.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
d. The woman’s support system is encouraged to stay until discharge.
y5 y5 y5 y5 y5 y5 y5 y5 y5
ANS: y 5 D
, Sleeping equipment is provided in a private room. A hospital setting is never a familiar
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
environment to new parents. An LDRP room is not less expensive than a traditional hospital
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
room. The baby remains with the mother at all times and is not removed to the nursery for
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
routine care or testing. The father or other designated members of the mother’s support system
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
are encouraged to stay at all times.
y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Assessment MSC: Patient Needs: Health Promotion and Maintenance
y5 y5 y 5 y5 y5 y5 y5 y5
4. Which nursing intervention is an independent function of the professional nurse?
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
a. Administering oral analgesics y5 y5
b. Requesting diagnostic studies y5 y5
c. Teaching the patient perineal care y5 y5 y5 y5
d. Providing wound care to a surgical incision y5 y5 y5 y5 y5 y5
ANS: y 5 C
Nurses are now responsible for various independent functions, including teaching, counseling,
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
and intervening in nonmedical problems. Interventions initiated by the physician and carried
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
out by the nurse are called dependent functions. Administrating oral analgesics is a dependent
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
ystudies is a dependent function. Providing wound care is a dependent function; however, the
5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
physician prescribes the type of wound care through direct orders or protocol.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Assessment MSC: Patient Needs: Safe and Effective Care Environment
y5 y5 y 5 y5 y5 y5 y5 y5 y5
5. Which response by the nurse is the most therapeutic when the patient states, “I’m so afraid to
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
have a cesarean birth”?
y5 y5 y5 y5
a. “Everything will be OK.” y5 y5 y5
b. “Don’t worry about it. It will be over soon.” y5 y5 y5 y5 y5 y5 y5 y5
c. “What concerns you most about a cesarean birth?” y5 y5 y5 y5 y5 y5 y5
d. “The physician will be in later and you can talk to him.”y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
ANS: y 5 C
The response, “What concerns you most about a cesarean birth” focuses on what the patient is
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
saying and asks for clarification, which is the most therapeutic response. The response,
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
“Everything will be ok” is belittling the patient’s feelings. The response, “Don’t worry about
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
it. It will be over soon” will indicate that the patient’s feelings are not important. The response,
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
“The physician will be in later and you can talk to him” does not allow the patient to verbalize
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
her feelings when she wishes to do that.
y5 y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Application OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Implementation MSC: Patient Needs: Psychosocial Integrity
y5 y5 y 5 y5 y5 y5
6. In which step of the nursing process does the nurse determine the appropriate interventions for
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
y5 the identified nursing diagnosis?
y5 y5 y5
a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: y 5 A
, The third step in the nursing process involves planning care for problems that were identified during
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
assessment. The evaluation phase is determining whether the goals have been met.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
During the assessment phase, data are collected. The intervention phase is when the plan of care
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
is carried out.
y5 y5 y5
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Planning MSC: Patient Needs: Safe and Effective Care Environment
y5 y5 y 5 y5 y5 y5 y5 y5 y5
7. Which goal is most appropriate for the collaborative problem of wound infection?
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
a. The patient will not exhibit further signs of infection.
y5 y5 y5 y5 y5 y5 y5 y5
b. Maintain the patient’s fluid intake at 1000 mL/8 hour. y5 y5 y5 y5 y5 y5 y5 y5
c. The patient will have a temperature of 98.F within 2 days.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
d. Monitor the patient to detect therapeutic response to antibiotic therapy.
y5 y5 y5 y5 y5 y5 y5 y5 y5
ANS: y 5 D
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
interventions of monitoring or observing. Monitoring for complications such as further signs of
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
infection is an independent nursing role. Intake and output is an independent nursing role.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
Monitoring a patient’s temperature is an independent nursing role.
y5 y5 y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Application OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Planning MSC: Patient Needs: Safe and Effective Care Environment
y5 y5 y 5 y5 y5 y5 y5 y5 y5
8. Which nursing intervention is written correctly?
y5 y5 y5 y5 y5
a. Force fluids as necessary. y5 y5 y5
b. Observe interaction with the infant. y5 y5 y5 y5
c. Encourage turning, coughing, and deep breathing. y5 y5 y5 y5 y5
d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
ANS: y 5 D
Interventions might not be carried out if they are not detailed and specific. “Force fluids” is not
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
specific; it does not state how much or how often. Encouraging the patient to turn, cough, and
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
breathe deeply is not detailed or specific. Observing interaction with the infant does not state
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
how often this procedure should be done. Assisting the patient to ambulate for 10 minutes
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
within a certain timeframe is specific.
y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Application OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Planning MSC: Patient Needs: Safe and Effective Care Environment
y5 y5 y 5 y5 y5 y5 y5 y5 y5
9. The patient makes the statement: “I’m afraid to take the baby home tomorrow.” Which
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
y5 response by the nurse would be the most therapeutic?
y5 y5 y5 y5 y5 y5 y5 y5
a. “You’re afraid to take the baby home?” y5 y5 y5 y5 y5 y5
b. “Don’t you have a mother who can come and help?” y5 y5 y5 y5 y5 y5 y5 y5 y5
c. “You should read the literature I gave you before you leave.”
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
d. “I was scared when I took my first baby home, but everything worked out.”
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
ANS: y 5 A
y5 y5 y5 y5 y5 y5
Health Nursing 8th Edition By Sharon Smith Murray
y5 y5 y5 y5 y5 y5 y5 y5
,Chapter 1. Clinical Judgement and the Nursing Process
y5 y5 y5 y5 y5 y5 y5
Foundations of Maternal-Newborn & Women’s Health Nursing, 8th Edition
y5 y5 y5 y5 y5 y5 y5 y5
MULTIPLE CHOICE y5
1. A nurse educator is teaching a group of nursing students about the history of family-centered
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
y5 maternity care. Which statement should the nurse include in the teaching session?
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
a. The Sheppard-Towner Act of 1921 promoted family-centered care.
y5 y5 y5 y5 y5 y5 y5
b. Changes in pharmacologic management of labor prompted family-centered care. y5 y5 y5 y5 y5 y5 y5 y5
c. Demands by physicians for family involvement in childbirth increased the practice y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
of family-centered care.
y5 y5 y5
d. Parental requests that infants be allowed to remain with them rather than in ay5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
nursery initiated the practice of family-centered care.
y5 y5 y5 y5 y5 y5 y5
ANS: y 5 D
As research began to identify the benefits of early, extended parent–infant contact, parents
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
began to insist that the infant remain with them. This gradually developed into the practice of
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
rooming-in and finally to family-centered maternity care. The Sheppard-Towner Act provided
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
funds for state-managed programs for mothers and children but did not promote
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
family-centered care. The changes in pharmacologic management of labor were not a factor in y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
family-centered maternity care. Family-centered care was a request by parents, not physicians.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Application OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Planning MSC: Patient Needs: Health Promotion and Maintenance
y5 y5 y 5 y5 y5 y5 y5 y5
2. Expectant parents ask a prenatal nurse educator, “Which setting for childbirth limits the
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
amount of parent–infant interaction?” Which answer should the nurse provide for these
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
parents in order to assist them in choosing an appropriate birth setting?
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
a. Birth center y5
b. Home birth y5
c. Traditional hospital birth y5 y5
d. Labor, birth, and recovery room y5 y5 y5 y5
ANS: y 5 C
In the traditional hospital setting, the mother may see the infant for only short feeding periods,
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
and the infant is cared for in a separate nursery. Birth centers are set up to allow an increase in
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
parent–infant contact. Home births allow the greatest amount of parent–infant contact. The
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
labor, birth, recovery, and postpartum room setting allows for increased parent–infant contact.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Planning MSC: Patient Needs: Health Promotion and Maintenance
y5 y5 y 5 y5 y5 y5 y5 y5
3. Which statement best describes the advantage of a labor, birth, recovery, and postpartum
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
y5 (LDRP) room? y5
a. The family is in a familiar environment.
y5 y5 y5 y5 y5 y5
b. They are less expensive than traditional hospital rooms.
y5 y5 y5 y5 y5 y5 y5
c. The infant is removed to the nursery to allow the mother to rest.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
d. The woman’s support system is encouraged to stay until discharge.
y5 y5 y5 y5 y5 y5 y5 y5 y5
ANS: y 5 D
, Sleeping equipment is provided in a private room. A hospital setting is never a familiar
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
environment to new parents. An LDRP room is not less expensive than a traditional hospital
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
room. The baby remains with the mother at all times and is not removed to the nursery for
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
routine care or testing. The father or other designated members of the mother’s support system
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
are encouraged to stay at all times.
y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Assessment MSC: Patient Needs: Health Promotion and Maintenance
y5 y5 y 5 y5 y5 y5 y5 y5
4. Which nursing intervention is an independent function of the professional nurse?
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
a. Administering oral analgesics y5 y5
b. Requesting diagnostic studies y5 y5
c. Teaching the patient perineal care y5 y5 y5 y5
d. Providing wound care to a surgical incision y5 y5 y5 y5 y5 y5
ANS: y 5 C
Nurses are now responsible for various independent functions, including teaching, counseling,
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
and intervening in nonmedical problems. Interventions initiated by the physician and carried
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
out by the nurse are called dependent functions. Administrating oral analgesics is a dependent
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
ystudies is a dependent function. Providing wound care is a dependent function; however, the
5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
physician prescribes the type of wound care through direct orders or protocol.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Assessment MSC: Patient Needs: Safe and Effective Care Environment
y5 y5 y 5 y5 y5 y5 y5 y5 y5
5. Which response by the nurse is the most therapeutic when the patient states, “I’m so afraid to
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
have a cesarean birth”?
y5 y5 y5 y5
a. “Everything will be OK.” y5 y5 y5
b. “Don’t worry about it. It will be over soon.” y5 y5 y5 y5 y5 y5 y5 y5
c. “What concerns you most about a cesarean birth?” y5 y5 y5 y5 y5 y5 y5
d. “The physician will be in later and you can talk to him.”y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
ANS: y 5 C
The response, “What concerns you most about a cesarean birth” focuses on what the patient is
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
saying and asks for clarification, which is the most therapeutic response. The response,
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
“Everything will be ok” is belittling the patient’s feelings. The response, “Don’t worry about
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
it. It will be over soon” will indicate that the patient’s feelings are not important. The response,
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
“The physician will be in later and you can talk to him” does not allow the patient to verbalize
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
her feelings when she wishes to do that.
y5 y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Application OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Implementation MSC: Patient Needs: Psychosocial Integrity
y5 y5 y 5 y5 y5 y5
6. In which step of the nursing process does the nurse determine the appropriate interventions for
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
y5 the identified nursing diagnosis?
y5 y5 y5
a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: y 5 A
, The third step in the nursing process involves planning care for problems that were identified during
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
assessment. The evaluation phase is determining whether the goals have been met.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
During the assessment phase, data are collected. The intervention phase is when the plan of care
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
is carried out.
y5 y5 y5
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Planning MSC: Patient Needs: Safe and Effective Care Environment
y5 y5 y 5 y5 y5 y5 y5 y5 y5
7. Which goal is most appropriate for the collaborative problem of wound infection?
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
a. The patient will not exhibit further signs of infection.
y5 y5 y5 y5 y5 y5 y5 y5
b. Maintain the patient’s fluid intake at 1000 mL/8 hour. y5 y5 y5 y5 y5 y5 y5 y5
c. The patient will have a temperature of 98.F within 2 days.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
d. Monitor the patient to detect therapeutic response to antibiotic therapy.
y5 y5 y5 y5 y5 y5 y5 y5 y5
ANS: y 5 D
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
interventions of monitoring or observing. Monitoring for complications such as further signs of
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
infection is an independent nursing role. Intake and output is an independent nursing role.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
Monitoring a patient’s temperature is an independent nursing role.
y5 y5 y5 y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Application OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Planning MSC: Patient Needs: Safe and Effective Care Environment
y5 y5 y 5 y5 y5 y5 y5 y5 y5
8. Which nursing intervention is written correctly?
y5 y5 y5 y5 y5
a. Force fluids as necessary. y5 y5 y5
b. Observe interaction with the infant. y5 y5 y5 y5
c. Encourage turning, coughing, and deep breathing. y5 y5 y5 y5 y5
d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
ANS: y 5 D
Interventions might not be carried out if they are not detailed and specific. “Force fluids” is not
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
specific; it does not state how much or how often. Encouraging the patient to turn, cough, and
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
breathe deeply is not detailed or specific. Observing interaction with the infant does not state
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
how often this procedure should be done. Assisting the patient to ambulate for 10 minutes
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
within a certain timeframe is specific.
y5 y5 y5 y5 y5 y5
DIF: Cognitive Level: Application OBJ: Nursing Process Step: y5 y5 y 5 y5 y5
Planning MSC: Patient Needs: Safe and Effective Care Environment
y5 y5 y 5 y5 y5 y5 y5 y5 y5
9. The patient makes the statement: “I’m afraid to take the baby home tomorrow.” Which
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
y5 response by the nurse would be the most therapeutic?
y5 y5 y5 y5 y5 y5 y5 y5
a. “You’re afraid to take the baby home?” y5 y5 y5 y5 y5 y5
b. “Don’t you have a mother who can come and help?” y5 y5 y5 y5 y5 y5 y5 y5 y5
c. “You should read the literature I gave you before you leave.”
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
d. “I was scared when I took my first baby home, but everything worked out.”
y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5 y5
ANS: y 5 A
