A nurse gathers the following assessment data. Which cues form
a pattern suggesting a problem? Select all that apply. Correct
Answer Body temperature is 101°F (38.3°C).
Patient has drainage from surgical wound.
The skin around the wound is tender to the touch
A nurse is assessing a diabetic patient and notes a non-healing
ulcer on the patient's left foot. Which sequence should the nurse
follow while implementing a plan of care? Correct Answer 1.
Review all possible interventions for the patient.
3.
Review all possible consequences associated with the
interventions.
2.
Determine the probability of possible consequences
4.
Make a prediction of what will happen to the patient as a
consequence of an intervention.
A nurse is assessing a diabetic patient using Gordon's model of
functional health patterns. Which pattern is not part of the
functional pattern in Gordon's model? Correct Answer
Dependence-independence
A nurse is assessing an athlete hospitalized for ankle surgery.
The nurse notes a quiver in the patient's voice and fidgety hands
and legs as he expresses his worry about not being able to play.
,Which data helps the nurse choose anxiety (ICNP) as a
diagnostic label? Select all that apply. Correct Answer Fidgety
hands and legs
Impending ankle surgery
Verbal expression of worry
Quiver in the patients' voice while talking
A nurse is observing the nonverbal cues of a patient who has a
quick and purposeful gait. Which feeling would the patient's gait
indicate? Correct Answer Confident
A nurse is scheduled to teach a group of morbidly obese patients
the significance of proper eating habits and exercise. Which
setting would be ideal to impart this teaching? Correct Answer
Classroom
A nurse is talking to an elderly patient and exploring the
patient's spiritual needs. Which type of communication is being
used? Correct Answer Interpersonal
A nurse is teaching a patient how to administer an epinephrine
injection in case of a severe allergic reaction. The nurse instructs
the patient to hold the injection like a dart. Which instructional
method did the nurse use? Correct Answer Analogy
A nurse is teaching a young adult patient how to adjust insulin
dosages based on the blood sugar results. This is an example of
which type of learning? Correct Answer Cognitive
, A nurse manager is educating the nursing staff on the
importance of security with the implementation of the electronic
health record (EHR) system. Which points does the manager
emphasize? Select all that apply. Correct Answer Do not share
passwords with anyone.
Do not log in with someone else's user access.
Do not leave the patient's medical record open on a computer
screen
A nurse performs various physical care techniques when caring
for a patient. Which actions are examples of physical care
techniques? Select all that apply. Correct Answer Staying
organized while caring for the patient
Protecting oneself and the patient from injury
Using proper hygienic infection control practices
A nurse would use the body systems model for which purpose?
Correct Answer organize patient data
A nurse, after administering antibiotics, updates a patient's chart.
Which elements of the report does the nurse accurately
document to limit the nursing liability in case of a legal claim?
Select all that apply. Correct Answer Drug allergies
Discontinued medications
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