NURS 200 Final Exam (Questions and Answers)

NURS 200 Final Exam (Questions and Answers) NURS 200 Final Exam Chap 11 Question 1 The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose o ...

NURS 200 Final Exam (Questions and Answers) NURS 200 Final Exam Chap 11 Question 1 The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients. Correct Answer: 3 Question 2 While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Correct Answer: 1 Question 3 During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says leave me alone. Which subjective data should the nurse document? 1. Restlessness 2. Leave me alone 3. Not talkative 4. Pale and diaphoretic Correct Answer: 2 Question 4 Family of a client demonstrating confusion state that this is not the clients usual behavior. How should the nurse document this data? 1. Inference 2. Subjective data 3. Objective data 4. Secondary subjective data Correct Answer: 3 Question 5 The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the clients pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Correct Answer: 3 Question 6 A new client has been admitted to the care area. How soon should the nurse plan to complete a physical assessment on this patient? 1. 1 hour 2. 12 hours 3. 48 hours 4. 24 hours Correct Answer: 4 Question 7 The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client? 1. Medical record from the childbirth 2. Grandmother 3. Parents 4. Admitting physician Correct Answer: 3 Question 8 A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client? 1. In order to make sure all of your information is complete, I need to ask these questions. 2. Youre right. Let me know if theres anything you need right now. 3. Ill be done shortly, just give me a few more minutes. 4. You shouldnt be upset. Were only doing our jobs. Correct Answer: 2 Question 9 The nurse documents: Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse. Which method of data collection does this documentation demonstrate? 1. Examining 2. Interviewing 3. Listening 4. Observing Correct Answer: 4 Question 10 A nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for this particular nurse? 1. A client with audible breathing 2. Moaning of a client in pain 3. Whirring of ventilators 4. Co-orkers discussing their clients conditions Correct Answer: 3 Question 11 A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority). Standard Text: Click and drag the options below to move them up or down. Choice 1. The family is at the bedside. Choice 2. The IV pump is running on battery. Choice 3. The ECG monitor shows tachycardia. Choice 4. The client reports being restless. Choice 5. O2 tubing is not attached to wall regulator. Correct Answer: 3, 4, 5, 2, 1 Question 12 During an initial interview, the client says I dont understand why I have to have surgery; Im really not that sick or in pain right now. How should the nurse respond to the client? 1. Its OK to be worried. Surgery is a big step. 2. What kind of questions do you have about your surgery? 3. I think these are things you should be asking your doctor. 4. Have you had surgery before? Correct Answer: 2 Question 13 The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use? 1. How would you describe your sleep pattern? 2. Can you describe your coughing pattern? 3. Is there anything that makes your breathing worse? 4. What medications are you on? Correct Answer: 1 Question 14 The nurse is assessing a client level of pain. Which open-ended question should the nurse use for this situation? 1. Is your pain worse at night? 2. What brought you to the clinic? 3. How has the pain impacted your life? 4. Youre feeling down about having pain, arent you? Correct Answer: 3 Question 15 A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, what should the nurse do? 1. Sit next to the client, a few feet apart. 2. Sit behind a desk. 3. Stand at the side of the clients chair. 4. Stand at the counter to take notes during the interview. Correct Answer: 1 Question 16 A client in the emergency department has a non-lifethreatening wound. The unit is busy with other clients, families, and people in the waiting room. How should the nurse conduct an interview with this client? 1. Have the client wait until the department quiets down, as the wound is not too serious. 2. Tell the client to wait in the waiting room and fill out the paperwork. 3. Draw curtains around the client and nurse to provide as much privacy as possible. 4. Make sure the clients back is to the rest of the room so as not to be heard by passersby. Correct Answer: 3 Question 17 A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this clients interview? 1. As soon as the client gets to the floor 2. After the client has settled in and been oriented to the room 3. When the family is available to help 4. After the client has been medicated Correct Answer: 2 Question 18 A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client? 1. Have a member of the housekeeping staff who speaks the same language translate. 2. Use the translation services supplied by the hospital. 3. Make sure a family member who does speak English is available. 4. Conduct the interview using hand gestures. Correct Answer: 2 Question 19 The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this client? 1. Hello, Im your nurse and Ill be taking care of you today. 2. Youre luckythere are no students on the unit today. 3. Good morning, is there anything you need right now? 4. Hi. If you need anything, put on your call light. Correct Answer: 1 Question 20 The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the interview is in the closing phase? 1. Im going to set up your physical assessment now. Do you have any questions? 2. Tell me more about how you feel. 3. Could you give examples of what types of other treatments youve had? 4. Is there anything youre worried about? Correct Answer: 1 Question 21 During an assessment interview, the client states that an elective surgical procedure will not be done because it does not fit into the clients life goals. Into which of Gordons functional health patterns should the nurse identify this clients comment? 1. Cognitive/perceptual pattern 2. Coping/stress-tolerance pattern 3. Health-perception/health-management pattern 4. Value/belief pattern Correct Answer: 4 Question 22 The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to this conclusion? 1. Observation of cues 2. Validation 3. Inference 4. Judgment Correct Answer: 3 Question 23 The nurse is reviewing the nursing process with a first-year nursing student. What should the nurse explain as being the purpose of the diagnosis phase? Standard Text: Select all that apply. 1. Develop a list of problems. 2. Identify client strengths. 3. Develop a plan. 4. Specify goals and outcomes. 5. Identify problems that can be prevented. Correct Answer: 1, 2, 5 Question 24 The nurse decides to seek wound care alternatives for a clients stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning? 1. Diagnosis 2. Implementation 3. Evaluation 4. Assessment Correct Answer: 3 Question 25 While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time? 1. Initial assessment 2. Problem-focused assessment 3. Emergency assessment 4. Time-lapsed assessment Correct Answer: 3 Question 26 Unlicensed assistive personnel measure a newly admitted clients vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data? 1. Retake the vital signs. 2. Call the physician. 3. Continue with the physical assessment as soon as possible. 4. Report the findings to the charge nurse. Correct Answer: 1 Question 27 A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database? Standard Text: Select all that apply. 1. Reports from physical therapy the client received as an outpatient 2. Documentation of the nurses physical assessment 3. Physicians orders 4. A list of current medications 5. Information about the clients cultural preferences 6. Discharge instructions Correct Answer: 1, 2, 4, 5 Question 28 The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing effective communication guidelines? Standard Text: Select all that apply. 1. Looking directly at the client to ensure good eye contact 2. Managing the conversation to avoid periods of silence 3. Providing personal experiences to help the client focus 4. Sitting in a chair next to the client who is in bed 5. Keeping arms unfolded and in a relaxed position Correct Answer: 1, 4, 5 Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1.Identifying major problems or needs 2.Organizing data in the client’s family history 3.Establishing short-term and long-term goals 4.Administering an antibiotic Correct Answer: 1 Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care? 1.Proposes hypotheses. 2.Generates desired outcomes. 3.Reviews results of laboratory tests. 4.Documents care. Correct Answer: 3 Which of the following elements is best categorized as secondary subjective data? 1.The nurse measures a weight loss of 10 pounds since the last clinic visit. 2.Spouse states the client has lost all appetite. 3.The nurse palpates edema in lower extremities. 4.Client states severe pain when walking up stairs. Correct Answer: 2 The nurse wishes to determine the client’s feelings about a recent diagnosis. Which interview question is most likely to elicit this information? 1.“What did the doctor tell you about your diagnosis?” 2.“Are you worried about how the diagnosis will affect you in the future?” 3.“Tell me about your reactions to the diagnosis.” 4.“How is your family responding to the diagnosis?” Correct Answer: 3 The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1.Correlation of the data with other members of the health care team 2.Demonstration of cost-effective care 3.Utilization of creativity and intuition in creating a plan of care 4.Collection of all necessary information for a thorough appraisal Correct Answer: 4 Question 29 Nursing activities that represent the various characteristics of the nursing process includes the nurses: Standard Text: Select all that apply. 1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature. 2. Advocating for a client who is mentally incapable of expressing her needs. 3. Deciding to increase a clients nasal oxygen based on his current pulse oxygenation levels. 4. Documenting all clients pain level responses after the administration of pain medication. 5. Attending in-services on a new hydraulic lift to be used to support safe client care. Correct Answer: 1,2,3,4 Chap 12 Question 1 After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses? 1. The ones that the nurse is licensed to treat 2. The ones that address other health professionals interventions 3. The ones that focus on the clients primary illness 4. The ones that have standardized care available Correct Answer: 1 Question 2 A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client? 1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis Correct Answer: 3 Question 3 A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client? 1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Wellness diagnosis Correct Answer: 1 Question 4 The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label? 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medical diagnoses for nursing 4. Promotes a taxonomy of nursing Correct Answer: 4 Question 5 An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in this clients plan of care? 1. The clients eyes are closed. 2. The clients skin is pale and mottled. 3. The clients spouse is asleep in the chair next to the bed. 4. The television is on and the volume is turned up. Correct Answer: 2 Question 6 The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis? 1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends families. 2. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities. 3. The grandparents go to weekly services and have formal interaction with clergy. 4. The children have attended private, religious schools, and the parents are involved in the schools activities. Correct Answer: 1 Question 7 The graduate nurse is struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues? 1. Depend on knowledge gained from peers experiences. 2. Work with seasoned and experienced nurses and learn from them. 3. Take assessment notes and utilize information from textbooks for comparison. 4. Know that this will take time, and experience is the best teacher. Correct Answer: 3 Question 8 ........continued