Nursing Process Exam 3 Questions and Answers (Graded A)

A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained. The nurse is curren ...

A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained. The nurse is currently involved in which step of the nursing process? a. Assessment b. Implementation c. Evaluation d. Diagnosing - ANSWER-a. Assessment The nurse is admitting a patient to the unit and asks the patient about the health history. The nurse is engaged in which component of the nursing process? a. Evaluation b. Diagnosis c. Assessment d. Planning - ANSWER-c. Assessment A postoperative patient is continuing to have incisional pain. As part of the nurses assessment, the nurse notes that the patient is grimacing when he or she changes position. The patients grimace can be useful in the assessment and can be described as which of the following? a. Cue b. Inference c. Diagnosis d. Health pattern - ANSWER-a. Cue A postoperative patient has denied the need for pain medication. The nurse has noted that the patient describes the pain as a 1 on a 0 to 10 scale. The nurse also notes that the patient grimaces when he or she changes position and guards the incision. The nurse believes that the patient is experiencing pain based on the information gathered in the assessment. What is this phenomenon known as? a. Cue b. Inference c. Diagnosis d. Health pattern - ANSWER-b. Inference A nurse is collecting data during the assessment of a patient. During the assessment, the nurse collects both subjective and objective data. Which information should the nurse consider as subjective data? a. Heart rate of 96 b. Incisional erythema c. Emesis of 150 mL d. Sharp, burning pain - ANSWER-d. Sharp, burning pain The nurse has just completed an assessment on a patient with a fractured right femur. Which data will the nurse categorize as objective? a. The patients toes of right foot are warm and pink. b. The patient reports a dull ache in the right hip. c. The patient says feels tired all the time. d. The patient is concerned about insurance coverage. - ANSWER-a. The patients toes of right foot are warm and pink A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a nurse. As the student nurse charts the interaction, which statement is the best way to document what happened? a. Appears to be in pain as evidenced by grouchy behavior b. Behavior is inappropriate, requests registered nurse do the assessment c. States, I want a registered nurse to do my assessment d. Is grumpy, registered nurse notified - ANSWER-c. States, I want a registered nurse to do my assessment A mother of five children is admitted to the hospital for abdominal pain. The nurse asks a series of questions before performing a physical assessment. The patient answers the questions. When asking the patient some other questions, the patients spouse starts to answer. As the admission process progresses and the nurse gathers subjective data, the nurse requests that the patient answer the next questions. What is the rationale for the nurses behavior? a. The patient is exhibiting confusion. b. The spouse is being obnoxious. c. The patient is the best source of information. d. The spouse is too controlling. - ANSWER-c. The patient is the best source of information. A 2-year-old patient is being admitted to the outpatient surgery for a tonsillectomy. Which will provide the best primary source of information for what comforts the patient when stressed? a. Patient chart b. Patient c. Parents d. Surgeon - ANSWER-c. Parents A nurse is interviewing a patient being admitted to the hospital for surgery. During the interview, the nurse introduces self and explains that will be gathering some information. The nurse is in which phase of the interview? a. Orientation b. Working c. Assessment d. Termination - ANSWER-a. Orientation A nurse is teaching the staff about the phases of the interview process. Which information should the nurse include in the teaching session? a. Orientation, working, termination b. Orientation, assessment, evaluation c. Planning, assessment, termination d. Planning, assessment, evaluation - ANSWER-a. Orientation, working, termination Which question or comment should the nurse initially use that would best gather the most information during a health history assessment? a. Let us help you. b. Did you seek help when it first started? c. Tell me about the problems you are having. d. Do you have a family history of this problem? - ANSWER-c. Tell me about the problems you are having. As a nurse is obtaining a health history from a patient, the nurse uses comments such as go on. Which technique is the nurse using? a. Cues b. Inferences c. Back-channeling d. Termination - ANSWER-c. Back-channeling A patient with a history of seizures is being admitted to the hospital after a grand mal seizure took place at a shopping mall. The patients spouse accompanied the patient to the hospital and is being interviewed by the nurse. Which question should the nurse ask to quickly focus on the patients symptoms? a. What made you choose this hospital? b. How long did the seizure last? c. Tell me how the seizure disorder has affected the family. d. Tell me why you brought your spouse to the hospital today. - ANSWER-b. How long did the seizure last? A patient is admitted to the hospital after a motorcycle accident. The nurse in the emergency room is assessing vital signs, general appearance and behavior, and performing a head-to-toe examination of all body systems. What is the nurse doing? a. Making a medical diagnosis b. Performing a physical examination c. Making an evaluation d. Performing data validation - ANSWER-b. Performing a physical examination When admitting a patient to the hospital, the nurse asks if has problems eating since the patient had a stroke. The patient denies any problems and states that does not require assistance. After lunch, the nurse notes that the patient has not eaten most of the food and has spilled much of the food. These cues lead the nurse to believe that the patient is not functioning at the level indicated upon admission. The nurse is using which type of information to make this deduction? a. Verbal behavior b. Physical assessment c. Nursing diagnosis d. Nonverbal behavior - ANSWER-d. Nonverbal behavior A 67-year-old male patient of French heritage is admitted to the hospital. The patient is interviewed by a nurse from a Korean family. The nurse did not make eye contact with the patient while conducting the interview. This disturbed the patient because the patient thought that the nurse might be trying to hide something. Which factor most likely influenced the behavior of the nurse and patient? a. Culture b.