Sherpath Module 2 Quiz
1. The nurse makes the following entry on the patient’s care plan: Goal not met. Patient
refuses to walk and states, I’m afraid of falling. The nurse should:
2. The nurse observes a confused
...
Sherpath Module 2 Quiz
1. The nurse makes the following entry on the patient’s care plan: Goal not met. Patient
refuses to walk and states, I’m afraid of falling. The nurse should:
2. The nurse observes a confused patient pacing back and forth in the dining room. The patient yells, the doctor is going to make us all drink poison! The most appropriate intervention at this time would be to:
3. Professional nursing requires a commitment to lifelong learning because:
4. The nurse is caring for a patient admitted to the psychiatric unit as a result of an overdose of cocaine. Which nursing diagnosis indicates an understanding of a nursing diagnostic statement?
5. After the patient’s data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. The framework that provides the most holistic view of the patient’s condition is:
6. The nurse is gathering data on a patient with acute bacterial pneumonia. This is an example of which step of the nursing process?
7. The wound care nurse is assessing a non-healing leg wound on a patient recently admitted for uncontrolled diabetes. The nurse organizes the data using Gordon’s Functional Health Pattern of:
8. A nurse completes a care plan for an assigned patient diagnosed with an inflammation of the pericardium. Which diagnosis written on the plan indicates a need for further
instruction on using the nursing process?
9. When creating a nursing diagnosis, the related factor:
10. The nursing student is observing a staff nurse demonstrating a subcutaneous injection during a skills competency fair. The student tells the nurse that nursing textbooks indicate that aspirating for blood is not necessary. The nurse replies, “I prefer to check for blood, just in case. This is the way I learned to give shots and it works for me.” The nurse’s response is most likely related to:
11. The nurse is caring for a patient with lung disease. The patient tells the nurse that the most important thing to do during the shift is to walk down to the nurses’ station and back without having shortness of breath. The patient’s request is an example of which nursing theory?
12. During the health history interview, the patient tells the nurse, “Just walking to the mailbox and back makes my calves ache. Is this normal?” Which of the following
frameworks would the nurse most likely choose to document this data?
13. After the patient’s data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. The framework that provides the most holistic view of the patient’s condition
is:
14. Patient-centered care requires the nurse to:
15. The nurse is preparing to begin a physical examination for a patient with open lesions on
the lower extremities. Which should the nurse evaluate during the physical assessment?
16. The wound care nurse is assessing a non-healing leg wound on a patient recently admitted for uncontrolled diabetes. The nurse organizes the data using Gordon’s
Functional Health Pattern of:
17. A patient is receiving an experimental drug for leukemia. The nurse is worried that the drug may cause a reduction in platelets leading to intestinal tract bleeding. Which type of
nursing diagnosis should the nurse use to address this concern?
18. North American Nursing Diagnosis Association International (NANDA-I) is an organization focusing on revising nursing diagnosis taxonomy and evaluates nursing research to validate the diagnostic labels. The NANDA-I taxonomy and new nursing
diagnoses are published every:
19. Touch is the intentional physical contact between two or more people. It occurs so often in patient care situations that it has been deemed to be an essential and universal
component of nursing care. Task-oriented touch occurs when the nurse:
20. The nurse is admitting a patient with severe dehydration. Assessment data reveal a decreased blood pressure, an increased pulse rate, and a low circulating blood volume. The student observes that the patient is confused and restless. Which patient information would the nurse consider as a contributing factor when choosing the nursing diagnostic
label?
21. The nursing process is the foundation of professional nursing practice. As such, the
nursing process can be defined as:
22. The charge nurse is discussing a patient’s care plan during a team meeting. The team determines that the patient has not met the goal of “ambulating to the nurse’s station twice a day” and decides to revise the plan. Which of the following characteristics of the
nursing process most represents this decision?
23. The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The essential step that was added in 1991 is:
24. A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. The nurse asks the manager if there is a document
written by the physician for this type of reaction. The nurse is referring to a:
25. The nurse writes a short-term goal for a patient scheduled for surgery in the morning. The
goal that contains all of the necessary elements is:
26. The nurse observes a confused patient pacing back and forth in the dining room. The
patient yells, “The doctor is going to make us all drink poison!” The most appropriate intervention at this time would be to:
27. Which situation poses the greatest challenge to the nurse working with a child and family?
28. A helping relationship develops through ongoing, purposeful interaction between a nurse and a patient. Nurse–patient relationships focus on:
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