NUR 111 sample questions with correct answers 2024

More important than the actual stages of any given grief reaction is the idea that grief is a process that is the same from person to person. - answer-False Rationale: More important than the actual stages of any given grief reaction is the idea that grief is a process that varies from person to person. The goal of palliative care is to give patients with life-threatening illnesses the best quality of life they can have by the aggressive treatment of symptoms. - answer-True Rationale: The goal of palliative care is to give patients with life-threatening illnesses the best quality of life they can have by the aggressive treatment of symptoms. A living will appoints an agent, trusted by the person who is ill, to make decisions in the event of subsequent incapacity. - answer-False Rationale: A durable power of attorney appoints an agent, trusted by the person who is ill, to make decisions in the event of subsequent incapacity. An elderly person who is placed in a nursing home by his family is remorseful about the loss of his financial independence. What is the term for the type of loss he is experiencing? A. Physical loss B. Psychological loss C. Actual loss D. Perceived loss - answer-: D. Perceived loss Rationale: Perceived loss is felt by the person, but intangible to others, as is the case with loss of financial independence. Physical loss and actual loss can be recognized by others as well as the person sustaining the loss. Psychological loss may be caused by an altered self-image. The essential activities involved in the nursing process are assessing, _____________, planning, implementing, and evaluating. - answer-diagnosing As defined by the World Health Organization, health includes physical, social, and mental components and is not merely the absence of disease or infirmity. - answer-true The major goals of health care are promoting, maintaining, and restoring health - answer-true Graduates of a diploma nursing program are not eligible to take the NCLEX-RN examination - answer-false Reciprocity is the process that allows a nurse to apply for and be endorsed as a registered nurse by another state. - answer-true A current nursing trend for the next 10 to 20 years is an abundance of practicing nurses. - answer-false Nursing theories and nursing research provide a foundation for _________-based nursing practice that defines the rationale for nursing actions. - answer-evidence To meet the aims of nursing practice, the nurse uses four blended competencies: _____________, technical, interpersonal, and ethical/legal. - answer-cognitive Health promotion activities that are the framework for nursing activities are considered __________-centered. - answer-patient Nurse _________ Acts are laws established in each state in the United States to regulate the practice of nursing. - answer-Practice The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed?a.Comprehensive b.Initial c.Time-lapsed d.Quick priority - answer-d. Quick priority assessments (QPA) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care agency or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier. The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. a."The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths. " b."It's hospital policy. I know it must be tiresome, but I will try to make this quick!" c."I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." d."We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." e."We need to check your health status and see what kind of nursing care you may need." f."We need to see if you require a referral to a physician or other health care - answer-a, e, f. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination. When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate? a.Correct the initial assessment form. b.Redo the initial assessment and document current findings. c.Conduct and document an emergency assessment. d.Perform and document a focused assessment of skin integrity. - answer-d. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment. A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? a."There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" b."You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c."No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." d."Don't worry about learning all of the questions to ask. Every agency has its own assessment form you must use." - answer-b. Once you learn what constitutes the minimum data set, you can adapt this to any patient situation. It is not true that each assessment is the same even when you are using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard agency assessment tools does not allow for individualized patient care or critical thinking. The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply. a.A patient tells the nurse that she is feeling nauseous. b.A patient's ankles are swollen. c.A patient tells the nurse that she is nervous about her test results. d.A patient complains of having a rash on her arm that is itchy. e.A patient rates his pain as a 7 on a scale of 1 to 10. f.A patient vomits after eating supper. - answer-a, c, d, e. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, itchy, or chilly and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting. When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. What should the nurse do? a.Introduce oneself and thank the wife for being present. b.Introduce oneself and ask the wife if she wants to remain. c.Introduce oneself and ask the wife to leave. d.Introduce oneself and ask the patient if he would like the wife to stay. - answer-d. The patient has the right to indicate whom he would like to be present for the nursing history and exam. You should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife. A nurse is performing an initial comprehensive assessment of an 84-year-old male patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? a.Maslow's human needs b.Gordon's functional health patterns c.Human response patterns d.Body system model - answer-b. Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems. The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do? a.Inform the charge nurse. b.Inform the surgeon. c.Validate the finding. d.Document the finding. - answer-c. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate, thus all data should be validated before documentation if there are any doubts about accuracy. A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? a."You made an inference that she is fine because she has no complaints. How did you validate this?" b."She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." c."Sometimes everyone gets lucky. Why don't you try to help another patient?" d."Maybe you should reassess the patient. She has to have a problem—why else would she be here?" - answer-a. The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving. what are the 5 steps of the nursing process? - answer-1. Assessment 2. Diagnosing 3. Planning 4. Implementing 5. Evaluation diagnosing are to - answer-(1) identify how a person, group, or community responds to actual or potential health and life processes; (2) identify factors that contribute to or cause health problems (etiologies); (3) identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems Diagnosing: .........Assessment - answer-collecting data identifying cues and making inferences validating data clustering related data identifying patterns reporting and recording data Diagnosing: ...........clinical reasoning - answer-analyzing synthesizing reflecting drawing conclusions Diagnosing - answer-creating a list of suspected problems ruling out similar problems naming actual and potential problems and clarifying what causing or contributing to them determining risk factors that must be managed identifying resources , strength and areas for health promotions Nursing diagnosis: - answer-Describes patient problems nurses can treat independentl Medical diagnoses - answer-identify diseases Collaborative problems: - answer-Managed by using physician-prescribed and nursing-prescribed interventions nursing diagnoses focus on - answer-unhealthy responses to health and illness. may change from day to day as the patient's responses change. describe problems treated by nurses within the scope of practice. Four Steps of Data Interpretation and Analysis - answer-1.Recognizing significant data: Comparing data to standards 2.Recognizing patterns or clusters 3.Identifying strengths and problems 4.Identifying potential complications Reaching conclusions what is Myocardial infarction - answer-heart attack describes five types of nursing diagnoses: - answer-actual, what is really going on risk, not happened yet but could possible, possible problems wellness, syndrome PED stands for "problem," "etiology," and "defining characteristics." - answer-Problem—identifies what is unhealthy about patient (what caused it Etiology—identifies factors maintaining the unhealthy state Defining characteristics—identify the subjective and objective data that signal the existence of a problem (what i feel caused it) A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. a.The nurse uses the nursing interview to collect patient data. b.The nurse analyzes data collected in the nursing assessment. c.The nurse develops a care plan for the patient. d.The nurse points out the patient's strengths. e.The nurse assesses the patient's mental status. f.The nurse identifies community resources to help his family cope. - answer-b, d, f. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process. A nurse is caring for an older adult patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. a.Bronchial pneumonia b.Impaired gas exchange c.Ineffective airway clearance d.Potential complication: sepsis e.Infection related to pneumonia f.Risk for septic shock - answer-b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem. After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem?a.No problem b.Possible problem c.Actual nursing diagnosis d.Clinical problem other than nursing diagnosis - answer-.b. When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem. A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? a.Risk for Impaired Skin Integrity b.Related to prescribed bedrest c.As evidenced by d.As evidenced by reddened areas of skin on the heels and back - answer-b."Related to prescribed bedrest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem. A nurse is counseling a 60-year-old female patient who refuses to look at or care for a new colostomy. She tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? a.Collaborative problem b.Interdisciplinary problem c.Medical problem d.Nursing problem - answer-d. Nursing Problem, because it describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies. To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to: a.Compare this reading to standards. b.Check the taxonomy of nursing diagnoses for a pertinent label. c.Check a medical text for the signs and symptoms of high blood pressure. d.Consult with colleagues. - answer-a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis. When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." Which of the following comments is the nurse most likely to hear from the instructor? a."Hold on a minute . . . Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue." b."Job well done . . . you've identified this problem early and we can manage it before it becomes more acute." c."Is this an actual or a possible diagnosis?" d."This is a medical, not a nursing problem." - answer-. a. A data cluster is a grouping of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. There may be a reason for the lack of a bowel movement for 2 days, or it might be this individual's normal pattern. A nurse makes a clinical judgment that an African American male patient in a stressful job is more vulnerable to developing hypertension than White male patients in the same or similar situation. The nurse has formulated what type of nursing diagnosis? a.Actual b.Risk c.Possible d.Wellness - answer-b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis. A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? (1) Ineffective Coping related to inability to maintain marriage (2) Defensive Coping related to loss of job and economic security (3) Altered Thought Processes related to panic state (4) Decisional Conflict related to placement of parent in a long-term care facility a.(1) and (2) b.(3) and (4) c.(1), (2), and (3) d.All of the above - answer-d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause. A nurse writes nursing diagnoses for patients and their families visiting a community health clinic. Which nursing diagnoses are correctly written as three-part nursing diagnoses? (1) Disabled Family Coping related to lack of knowledge about home care of child on ventilator (2) Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-pound weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height weight charts (3) Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" (4) Spiritual Distress related to inability to accept diagnosis of terminal illness as evidence - answer-b. (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement. Maslow's Hierarchy of Human Needs - answer-•Physiologic needs •Safety needs •Love and belonging needs •Self-esteem needs •Self-actualization needs six aims to be met by health care systems with regard to the quality of care: - answer-•Safe: avoiding injury •Effective: avoiding overuse and underuse •Patient-centered: responding to patient preferences, needs, and values •Timely: reducing waits and delays •Efficient: avoiding waste •Equitable: providing care that does not vary in quality to all recipients S M A R T - answer-S - specific M - measurable A - attainable R - realistic T - time-bound •Expressing the patient outcome as a nursing intervention. Incorrect: "Offer Mr. Myer 60 mL fluid every 2 hours while awake." - answer-Correct: "Mr. Myer will drink 60 mL fluid every 2 hours while awake, beginning 2/24/15."•Using verbs that are not observable and measurable. Incorrect: "Mrs. Gaston will know how to bathe her newborn." - answer-Correct: "After attending the infant care class, Mrs. Gaston will correctly demonstrate the procedure for bathing her newborn." Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." These verbs are too general and cannot be measured. Verbs for writing outcomes should be observable and measurable (as listed previously).•Including more than one patient behavior/manifestation in short-term outcomes. Incorrect: "Patient will list dangers of smoking and stop smoking." - answer-Correct: "By next meeting, 3/11/15, the patient will (1) identify three dangers of smoking and (2) describe a plan he is willing to try to stop smoking. By 6/20/15, the patient will report that he no longer smokes."•Writing outcomes that are so vague that other nurses are unsure of the goal of nursing care.