GNUR 238 Reading Assessments Exam 1 | RATED 100%

GNUR 238 READING ASSESSMENT EXAM 1 Reading Assessment 1 – The Nursing Process 1. The nurse is attempting to develop nursing diagnoses for her patient. The nurse understands that nursing diagnoses: A. identify actual or potential problems as well as responses to a problem B. require naming patient problems using nursing diagnostic labels C. utilize objective data since subjective data are often inaccurate D. includes unvalidated data to determine an accurate and thorough diagnosis E. are similar to medical diagnoses since they both are labels for diseases 2. Which of the following examples given indicate objective data? A. Respirations – 24 breaths per minute B. Wound size – 3 cm x 2 cm C. Platelet count – 350,000 mm D. Complaints of severe abdominal pain E. Temperature – 98.4° F (36.8° C) 3. Which assessment made by the nurse should be addressed first? A. Reddened area to coccyx B. Decreased urinary C. Shortness of breath D. Drainage from surgical incision 4. The nurse has a thorough understanding of the planning phase of the nursing process when stating: A. “Patients should be included in the planning process” B. “Patient families should not interfere in the planning process” C. “The planning process should focus on short-term goals only” D. “Planning is the first phase of the nursing process” 5. The nursing process is an attempt to meet patient needs. As such, it: A. is linear in nature B. is dynamic and cyclic C. requires care plans to be re-evaluated occasionally D. does not allow care plans to be modified Reading Assessment 2 – Health History and Patient Safety 1. The nurse is caring for a confused, combative patient. Which action would be considered last by the nurse to control behavior of the client? A. Orient the patient frequently B. Apply restraints C. Move the patient to a room close to the nurse’s station D. Encourage the family to spend time with the patient. 2. The nurse knows that which of the following is an appropriate way to tie restraints? A. Knot tied to the bed frame B. Quick-release knot tied to the side rail C. Bow tied to the bed frame D. Quick-release knot tied to the bed frame 3. The patient has a nursing diagnosis of risk for falls. Which goal is most important? A. Patient will ambulate twice a day B. Patient will have no symptoms of infection C. Patient will perform activities of daily living D. Patient will have no injuries during hospital stay 4. What part of the stethoscope do nurses use to auscultate the chest? A. Press the bell firmly against the skin to hear sounds and vibrations B. The bell of the stethoscope is used to hear breath sounds C. The diaphragm of the stethoscope is used to hear heart sounds D. Either the bell or the diaphragm is used to auscultate the chest 5. During the history, the patient states that she does not use many drugs. What is the nurse’s appropriate response to this statement? A. “Tell me about the drugs you are using currently." B. "To some people six or seven is not many" C. "Do you mean prescription drugs or illicit drugs?" D. "How often are you using these drugs?"