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Exam (elaborations) NUR 109 Nursing questions and answers
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EXAM 2 NURSING 109 QUESTIONSAND ANSWERS
Which are examples of nursing diagnoses? *Select All That Apply.*
1. Risk for impaired skin/tissue integrity
2. Ineffective impulse control
3. Insufficient breast milk
4. Renal failure
5. Emphysema with chronic obstructive pulmonary disease (COPD)
*1. Risk for impaired skin/tissue integrity*
*2. Ineffective impulse control*
*3. Insufficient breast milk*
Rationales
Option 1: Nursing diagnoses often address risks, for example, that a client may be prone to skin
impairment.
Option 2:
Nursing diagnoses address the health status of clients, which often includes how effectively they
deal with their environment.
Option 3:
Nursing diagnoses address the health status of clients and include terminology such as
"deficient" and "insufficient." In this case, the diagnosis addresses a problem but not the
pathology of it.
Option 4:
Direct terms such as renal failure name the illness or disease, which is a medical diagnosis.
Option 5:
A diagnosis of emphysema with COPD is a medical diagnosis.
When working with a postoperative bariatric client, how can the nurse promote client
participation and adherence to the nursing plan? *Select All That Apply.*
1. Ensure the client feels comfortable asking questions.
, 2. Keep the instructions simple, clear, and as specific as possible.
3. Determine if the client's goals for weight loss are the same as those in the nursing plan.
4. Help the client set realistic goals.
5. Carry out goal implementation and interventions even when client doesn't "feel like it." *1.
Ensure the client feels comfortable asking questions.*
*2. Keep the instructions simple, clear, and as specific as possible.*
*3. Determine if the client's goals for weight loss are the same as those in the nursing plan.*
*4. Help the client set realistic goals.*
Rationales
Option 1: It is important that the client understands instructions and feels comfortable asking
questions for clarification.
Option 2:
By keeping instructions clear, simple, and specific, the client will be able to demonstrate
understanding of what is expected.
Option 3:
In order for the client to be successful in reaching goals and outcomes, he or she must have the
same goals and focus as the nursing plan.
Option 4:
Realistic goals are instrumental to compliance and adherence in order to yield positive
outcomes.
Option 5:
If the client doesn't want to engage in interventions, the nurse should apply critical thinking skills
to determine why and plan ways to get past this obstacle.
Which statement correctly identifies an outcome goal from the nursing diagnosis of "potential for
skin breakdown related to immobility"?
1. The client will have increased mobility.
2. The client will understand strategies for preventing skin breakdown.
3. The client will be moved periodically throughout the shift.
4. The client's skin will remain intact and healthy. *4. The client's skin will remain intact and
healthy.*
Rationales
Option 1: This is a goal statement for a nursing diagnosis of impaired mobility. It does not
address skin breakdown.
Option 2:
This is a goal statement for a nursing diagnosis of knowledge deficit. This does not address skin
breakdown.
Option 3:
This is a goal statement related to mobility of the client. This does not address skin breakdown.
Option 4:
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