Which of the following best describe the purpose of assessment? (Select all that
apply)
A.Determine a patients current and ongoing health status
B.Select interventions to address patients' needs
C.Communicate goals of care
D.Identify patient health risks and health-promotion activities
Give this one a try later!
ANS: A,D
Assessment is the systematic and continuous collection of data about a
patient for the purpose of determining the patient's current and ongoing
health status, predicting the patient's health risks, and identifying
appropriate health-promoting activities. Assessment establishes a data
base about the patient's perceived needs, health problems, and responses
to these problems
,During the process of reflection, what is the most appropriate question for a nurse to
ask himself or herself?
A."What could I have done differently?"
B."What's going on right now?"
C."How can the patient's status change?"
D."What should I do to communicate this information?"
Give this one a try later!
ANS: A
Reflection is the action of retrospectively making sense of occurrences,
experiences, situations, or decisions and learning from them. What did or
did not work? What could have been done differently to achieve better
outcomes?
The nurse is planning care for a new patient with unstable blood glucose levels.
Which should be the priority action by the nurse?
A.Establish a specific nursing diagnosis.
B.Complete an assessment on the client.
C.Create a plan of nursing care for the client.
D.Carry out solutions to manage the problem.
Give this one a try later!
ANS: B
The five steps of the nursing process are assessment, diagnosis, planning
implementation, and evaluation. The nurse should first perform a thorough
assessment and then create a nursing diagnosis based on the assessment
data. The nurse should then create a plan of care with nursing interventions
to address the diagnosis, follow the plan, and then evaluate the
effectiveness of the nursing interventions.
,Which of the following are clinical signs and symptoms of a systemic infection?
A.Fever
B.Edema
C.Malaise
D.Pain or tenderness
E.Tachycardia
Give this one a try later!
ANS: A,C,E
Signs and symptoms associated with a systemic infection include fever and
chills, fatigue/malaise, nausea and vomiting, fast heart rate (tachycardia),
headache. Signs and symptoms associated with localized infections
generally include redness, warmth, swelling/edema and pain or tenderness.
The nurse prioritizes care for a patient who is recovering from a below the knee
amputation secondary to complications of diabetes mellitus. Which intervention is
identified as the priority for this patient using Maslow's hierarchy of needs?
A.The nurse teaches the patient how to properly change dressings on the right-leg
amputation site.
B.The nurse teaches the patient proper home safety techniques to prevent diabetic
wounds.
C.The patient joins the local American Diabetes Association support group.
D.The patient attends classes to deal with body image.
Give this one a try later!
, ANS: A
When prioritizing care based on Maslow's hierarchy of needs, physiological
needs will come before safety, social, and esteem needs. Caring for an
amputation site is meeting a physiological need. Attending a class to deal
with body-image issues addresses an esteem need. Teaching the patient
about safety techniques to prevent diabetic wounds addresses a safety
need. Joining a support group meets an esteem need.
A client with an upper respiratory infection is receiving radiation treatments. What is
the reason the nurse explains the risk of infection to the client?
A.Radiation only kills the targeted cells.
B.Radiation is lethal to only cancerous cells.
C.Radiation is only destructive to tissue.
D.Radiation kills both cancerous and healthy cells.
Give this one a try later!
ANS: D
Some medical therapies may predispose an individual to infection.
Radiation treatments for cancer destroy not only cancerous cells but also
some normal cells, thereby rendering the client more vulnerable to
infection.
Which of the following nursing diagnoses is written correctly?
A.Risk for constipation R/T decreased daily activity and medication use AEB
abdominal pain and hard formed stool
B.Breast Cancer R/T to family history
C.Imbalanced Nutrition R/T insufficient funds in meal budget AEB body weight 20%
below ideal weight.
D.Deficient Knowledge R/T inaccurate follow through of instructions
apply)
A.Determine a patients current and ongoing health status
B.Select interventions to address patients' needs
C.Communicate goals of care
D.Identify patient health risks and health-promotion activities
Give this one a try later!
ANS: A,D
Assessment is the systematic and continuous collection of data about a
patient for the purpose of determining the patient's current and ongoing
health status, predicting the patient's health risks, and identifying
appropriate health-promoting activities. Assessment establishes a data
base about the patient's perceived needs, health problems, and responses
to these problems
,During the process of reflection, what is the most appropriate question for a nurse to
ask himself or herself?
A."What could I have done differently?"
B."What's going on right now?"
C."How can the patient's status change?"
D."What should I do to communicate this information?"
Give this one a try later!
ANS: A
Reflection is the action of retrospectively making sense of occurrences,
experiences, situations, or decisions and learning from them. What did or
did not work? What could have been done differently to achieve better
outcomes?
The nurse is planning care for a new patient with unstable blood glucose levels.
Which should be the priority action by the nurse?
A.Establish a specific nursing diagnosis.
B.Complete an assessment on the client.
C.Create a plan of nursing care for the client.
D.Carry out solutions to manage the problem.
Give this one a try later!
ANS: B
The five steps of the nursing process are assessment, diagnosis, planning
implementation, and evaluation. The nurse should first perform a thorough
assessment and then create a nursing diagnosis based on the assessment
data. The nurse should then create a plan of care with nursing interventions
to address the diagnosis, follow the plan, and then evaluate the
effectiveness of the nursing interventions.
,Which of the following are clinical signs and symptoms of a systemic infection?
A.Fever
B.Edema
C.Malaise
D.Pain or tenderness
E.Tachycardia
Give this one a try later!
ANS: A,C,E
Signs and symptoms associated with a systemic infection include fever and
chills, fatigue/malaise, nausea and vomiting, fast heart rate (tachycardia),
headache. Signs and symptoms associated with localized infections
generally include redness, warmth, swelling/edema and pain or tenderness.
The nurse prioritizes care for a patient who is recovering from a below the knee
amputation secondary to complications of diabetes mellitus. Which intervention is
identified as the priority for this patient using Maslow's hierarchy of needs?
A.The nurse teaches the patient how to properly change dressings on the right-leg
amputation site.
B.The nurse teaches the patient proper home safety techniques to prevent diabetic
wounds.
C.The patient joins the local American Diabetes Association support group.
D.The patient attends classes to deal with body image.
Give this one a try later!
, ANS: A
When prioritizing care based on Maslow's hierarchy of needs, physiological
needs will come before safety, social, and esteem needs. Caring for an
amputation site is meeting a physiological need. Attending a class to deal
with body-image issues addresses an esteem need. Teaching the patient
about safety techniques to prevent diabetic wounds addresses a safety
need. Joining a support group meets an esteem need.
A client with an upper respiratory infection is receiving radiation treatments. What is
the reason the nurse explains the risk of infection to the client?
A.Radiation only kills the targeted cells.
B.Radiation is lethal to only cancerous cells.
C.Radiation is only destructive to tissue.
D.Radiation kills both cancerous and healthy cells.
Give this one a try later!
ANS: D
Some medical therapies may predispose an individual to infection.
Radiation treatments for cancer destroy not only cancerous cells but also
some normal cells, thereby rendering the client more vulnerable to
infection.
Which of the following nursing diagnoses is written correctly?
A.Risk for constipation R/T decreased daily activity and medication use AEB
abdominal pain and hard formed stool
B.Breast Cancer R/T to family history
C.Imbalanced Nutrition R/T insufficient funds in meal budget AEB body weight 20%
below ideal weight.
D.Deficient Knowledge R/T inaccurate follow through of instructions
