Question 1

Determine which example is true of measurability within the context of the nursing diagnosis.

Accepted Answer

A)   The patient will list signs of infection such as redness, pain, swelling, and warmth by the end of the shift.
B)   The patient will be pain-free and then walk to the bathroom.
C)   The patient reported abdominal pain for 2 days but denies nausea, vomiting, and diarrhea.
D)   The patient received Dilaudid 1 mg IV and 2 hours later received Lortab 500/5. A

Question 2

Which of the following would be a priority nursing diagnosis for a 73-year-old male patient with heart failure?

Accepted Answer

A)   Constipation related to immobility
B)   Risk for infection related to IV lines
C)   Activity intolerance related to an imbalance of oxygen and demand
D)   Self-care deficit C

Question 3

Which statement by the nurse illustrates how a nursing patient assessment differs from a medical patient assessment?

Accepted Answer

A)   "The patient is able to stand for 30 seconds before walking 10 feet toward the bathroom without an assistive device."
B)   "The patient is fearful that he will not be discharged home after his hospitalization."
C)   "The patient stated he felt pain in his lower back after slipping on his icy driveway."
D)   "The patient experienced a persistent cough, and azithromycin was prescribed 6 weeks ago. Today, she presents with a recurrent cough, green sputum, and worsening shortness of breath." A

Question 4

Which of these strategies should be a priority when the nurse is planning care for a patient with hypertension?

Accepted Answer

A)   Obtain less expensive antihypertensive medications.
B)   Assist with dietary changes as the first action.
C)   Follow evidence-based guidelines for appropriate interventions.
D)   Teach about the impact of exercise on hypertension.

Question 5

The nurse is attempting to take the history of a newly admitted 92-year-old patient but is unable to obtain the information because of the patient's cognitive status. The nurse should:

Accepted Answer

A)   refuse to complete the admission without more information.
B)   contact the family for information on the patient's history.
C)   call the doctor in the emergency room for a history.
D)   ask another nurse to try to obtain the information from the patient.

Question 6

Which of the following would be an expected outcome for a patient who is 12 hours status post hip replacement?

Accepted Answer

A)   Increase mobility and decrease pain.
B)   Care for the catheter independently.
C)   Walk without assistance.
D)   Bathe daily in a tub.

Question 7

The nurse is planning care for a patient with hypertension and obesity. Which of the following is a reasonable and measurable outcome for the nursing diagnosis of noncompliance with treatment regimen related to side effects of medications?

Accepted Answer

A)   The patient will state two lifestyle modifications for weight management by (date certain) .
B)   The patient will be compliant with the treatment regimen by (date certain) .
C)   The patient will understand the disease process by (date certain) .
D)   The patient's blood pressure will never increase.

Question 8

Which of the following is an example of a measurable outcome for the patient who has undergone a surgical procedure with a pain rating of 7 on a scale of 0 to 10?

Accepted Answer

A)   The patient's pain will be under control by Sunday.
B)   The patient will have no pain by the end of this shift.
C)   The patient's pain will decrease by the end of shift on (date) .
D)   The patient's pain will decrease to 2 or lower by the end of shift on (date) .

Question 9

A nursing intervention directs the patient to be turned every 2 hours to prevent skin breakdown from immobility. Assessment findings on new reddened areas on the lateral aspects of the right knee and ankle are obtained. What is the most appropriate way for these findings to be used when the care plan is evaluated?

Accepted Answer

A)   The information will be added to the relevant area of the electronic medical record.
B)   The nursing diagnosis will be changed from an actual problem to a potential problem.
C)   The new intervention of calling the physician will be added to the care plan.
D)   The intervention will change to have the patient turned every hour.

Question 10

While the nurse is taking the health history, the patient states, "My father and grandfather both had heart attacks and were unable to be very active afterward." This statement is related to the functional health pattern of:

Accepted Answer

A)   activity-exercise.
B)   cognitive-perceptual.
C)   health perception-health management.
D)   coping-stress tolerance.

Question 11

The nurse is charting on the patient who is status post surgery for an abdominal abscess and notes: "Pt's temperature has not exceeded 37°C this shift." This is an example of a(n):

Accepted Answer

A)   intervention.
B)   outcome.
C)   plan.
D)   diagnosis or analysis.

Question 12

An RN team leader has one LPN and one medical assistant assigned to the unit. Which patient would be most appropriate to assign to the LPN?

Accepted Answer

A)   Right lower lobectomy, one day postoperatively, whose temperature went from 37.1°C to 38.3°C during the last shift
B)   72-year-old right hip replacement, 2 days postoperatively, complaining of leg and chest pain
C)   48-year-old female patient who had a laparoscopic appendectomy 8 hours ago: urine output 165 mL, Hgb 7 g/dL, and Hct 21%
D)   Post cerebral vascular accident 1 week ago who had a Dobhoff feeding tube inserted and is now on continuous feedings at 45 mL/hr

Question 13

A patient with pneumonia has been using the incentive spirometer four times daily while awake during his 3-day hospitalization. How would the nurse explore the effectiveness of this intervention?

Accepted Answer

A)   The nurse would ask whether the patient was breathing better.
B)   The nurse would add turn, cough, and deep breathing exercises.
C)   The nurse would watch the patient use the incentive spirometer.
D)   The nurse would auscultate the lungs for adventitious breath sounds.

Question 14

Which of the following is true about collaborative problems?

Accepted Answer

A)   Collaborative problems fall within the definition of nursing diagnoses.
B)   Collaborative problems are managed using two physicians.
C)   Collaborative problems require the nurse to monitor for changes in status.
D)   Collaborative problems emphasize prevention, treatment, or health promotion.

Question 15

An example of an intervention independently initiated by the nurse is:

Accepted Answer

A)   starting a teaching plan for the patient who will go home tomorrow.
B)   instituting diet restrictions with subsequent progression of diet as tolerated.
C)   sending an abnormal appearing urine sample to the lab for routine urinalysis.
D)   writing an order for aspirin for a headache.

Question 16

A patient admitted with a diagnosis of Alzheimer's disease is anxious and dehydrated, has reportedly not been eating, and has had a weight loss of 5 lb in 1 week. Which nursing diagnosis is a priority?

Accepted Answer

A)   Fluid volume deficit related to fluid loss
B)   Altered nutrition: Less than body requirements related to anorexia
C)   Fluid volume excess related to reduced urine output
D)   Risk for impaired skin integrity

Question 17

The nurse is admitting a 64-year-old Hispanic male patient to the rehabilitation facility following surgical intervention for a broken hip. The nurse should first assess which of the following?

Accepted Answer

A)   Self-care ability
B)   Self-esteem
C)   Communication
D)   Pain

Question 18

The nurse is planning care for an 82-year-old obese female patient with Alzheimer's dementia. The patient wanders, is unsteady on her feet, and is visually impaired. What should the nurse give priority to when developing the plan of care?

Accepted Answer

A)   Laboratory results
B)   Skin condition
C)   Safety
D)   Nutrition

Question 19

The nurse is using Gordon's 11 categories for data collection in performing a health assessment. Which of the following represents assessment of cognition?

Accepted Answer

A)   How educated is the patient?
B)   How does the patient describe his or her health?
C)   Is the patient well nourished?
D)   Has the patient had treatment for emotional problems?

Question 20

The nurse reviews assessment findings for assigned patients. Based on this information, which patient demands the nurse's immediate attention? The patient with:

Accepted Answer

A)   renal failure on dialysis whose WBC is 10,000 mm3 (normal) 
B)   abdominal aneurysm whose blood pressure is 170/90
C)   atrial fibrillation whose lab results show and INR of 2.5 (normal) 
D)   endocarditis who has a loud heart murmur

Exam 11: Providing Patient-Centered Care Through the Nursing Process