Davis Edge Quizzes (Nursing Process) with COMPLETE SOLUTION

Davis Edge Quizzes (Nursing Process) with COMPLETE SOLUTION A nurse is performing an assessment on a client who has been admitted for hip replacement surgery the next day. The client is tearful and appears very anxiou ...

Davis Edge Quizzes (Nursing Process) with COMPLETE SOLUTION A nurse is performing an assessment on a client who has been admitted for hip replacement surgery the next day. The client is tearful and appears very anxious. The nurse is considering "anxiety" as a nursing diagnosis but does not have enough information. Which would be the appropriate action? 1. Assume the anxiety is related to surgery. 2. Inform the physician that the client is anxious. 3. Ask the client to try to remain calm during the assessment. 4. Ask the client if there is anything in particular he or she is anxious about. - ✔✔4) Ask the client if there is anything in particular he or she is anxious about. Rationale: Asking open-ended questions can help identify specific reasons for anxiety, and the nurse can direct teaching and interventions toward alleviating anxiety based on the etiology. Why is the diagnosis step critical to the nursing process? 1. It connects the assessment with planning, interventions, and follow-up evaluation.2. Without a complete nursing diagnosis, insurance will not compensate the hospital. 3. It provides the physician with necessary information to make a medical diagnosis. 4. Nursing diagnoses are needed to support any therapeutic treatments and diagnostic testing. - ✔✔1. It connects the assessment with planning, interventions, and follow-up evaluation. Rationale: The nursing diagnosis step is critical because it links the assessment step, which precedes it, to all the steps that follow it. However, assessment data must be complete and accurate in order to make an accurate nursing diagnosis. Which is the best explanation of the difference between a medical diagnosis and a nursing diagnosis? 1. A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is geared toward the client's health status and how a nurse can help independently. 2. A medical diagnosis is made by a physician, and a nursing diagnosis is created by a nurse. 3.A medical diagnosis involves interventions and medical treatment, and a nursing diagnosis involves client comfort and activities of daily living. 4. A medical diagnosis determines the nursing diagnosis, while the nursing diagnosis has no bearing on the medical diagnosis. - ✔✔1. A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is geared toward the client's health status and how a nurse can help independently. Rationale: A medical diagnosis describes a disease, illness, or injury, and the purpose is to find pathology. A nursing diagnosis is a statement of client health status that nurses can identify, prevent, or treat independently. A nurse has created a plan of care that involves assisting a client with ambulation. She attempts to get the client out of bed, but the client is obese and unable to move without pain. What action should the nurse take? 1. Change the outcome goals. 2. Document the attempt to ambulate the client. 3. Request assistance with ambulating the client. 4. Amend the nursing diagnosis and interventions. - ✔✔3. Request assistance with ambulating the client.Rationale: The nurse should obtain the necessary assistance to ambulate the client, and make every effort to meet the outcome goals. Which are examples of cue clusters for a nursing diagnosis? Select All That Apply. 1. Hard, painful bowel movement approximately every 3 to 4 days; sedentary lifestyle; low dietary fiber intake; dry skin 2. Pain and limited range of motion in knees, use of walker, medical diagnosis of osteoarthritis 3. Sore throat, fever, inability to ambulate, medical diagnosis of depression 4. Dry skin, painful urination, epistaxis 5. Urinary incontinence, lower abdominal pain, bladder spasm - ✔✔Answer: 1, 2, 5