1. The nurse makes the following entry on the patient’s care plan: Goal not met. Patient
refuses to walk and states, I’m afraid of falling. The nurse should:
• modify the care plan in response to the patient’s condition and wishes.
2. The nurse observes a confused patient pacing back and forth in the dining room. The
patient yells, the doctor is going to make us all drink poison! The most appropriate
intervention at this time would be to:
• quietly ask the patient to explain the statement.
3. Professional nursing requires a commitment to lifelong learning because:
• nurses are expected to update and maintain competency.
• treatment modalities and technology continue to advance.
• critical thinking is essential in nursing.
4. The nurse is caring for a patient admitted to the psychiatric unit as a result of an overdose
of cocaine. Which nursing diagnosis indicates an understanding of a nursing diagnostic
statement?
• Risk for injury related to hallucinations
• Chronic confusion related to excessive stimulation of nervous system as
evidenced by impaired socialization
5. After the patient’s data are collected, validated, and interpreted, the nurse organizes the
information in a framework (format) that facilitates access by all members of the health
care team. The framework that provides the most holistic view of the patient’s condition
is:
• Marjory Gordon’s Functional Health Patterns.
6. The nurse is gathering data on a patient with acute bacterial pneumonia. This is an
example of which step of the nursing process?
• Assessment
7. The wound care nurse is assessing a non-healing leg wound on a patient recently
admitted for uncontrolled diabetes. The nurse organizes the data using Gordon’s
Functional Health Pattern of:
• nutrition and metabolism.