Exam (elaborations)
NURS 3632 University Of Texas - Arlington -NUR3632 Foundations Exam 2 Study
- Course
- NURS 3632
- Institution
- University Of Texas - Arlington
NURS 3632 University Of Texas - Arlington -NUR3632 Foundations Exam 2 Study
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NUR3632 Foundations Exam 2 Study. A nurse is prioritizing the following patient diagnoses
according to Maslow's hierarchy of human needs:
(1) Disturbed Body Image
(2) Ineffective Airway Clearance
(3) Spiritual Distress
(4) Impaired Social Interaction
Which answer choice below lists the problems in order of
highest priority to lowest priority based on Maslow's model?
2, 4, 1, 3
3, 1, 4, 2
2, 4, 3, 1
3, 2, 4, 1 Correct Answers a. 2, 4, 1, 3. Because basic needs
must be met before a person can focus on higher ones, patient
needs may be prioritized according to Maslow's hierarchy: (1)
physiologic needs, (2) safety needs, (3) love and belonging
needs, (4) self-esteem needs, and (5) self-actualization needs. #2
is an example of a physiologic need, #4 is an example of a love
and belonging need, #1 is an example of a self-esteem need, and
#3 is an example of a self-actualization need.
. A nurse is using critical pathway methodology for choosing
interventions for a patient who is receiving chemotherapy for
breast cancer. Which nursing actions are characteristics of this
system being used when planning care? Select all that apply.
The nurse uses a minimal practice standard and is able to alter
care to meet the patient's individual needs.
The nurse uses a binary decision tree for stepwise assessment
and intervention.
,The nurse is able to measure the cause-and-effect relationship
between pathway and patient outcomes.
The nurse uses broad, research-based practice recommendations
that may or may not have been tested in clinical practice.
The nurse uses preprinted provider orders used to expedite the
order process after a practice standard has been validated
through research.
The nurse uses a decision tree that provides intense specificity
and no provider flexibility. Correct Answers a, c. A critical
pathway represents a sequential, interdisciplinary, minimal
practice standard for a specific patient population that provides
flexibility to alter care to meet individualized patient needs. It
also offers the ability to measure a cause-and-effect relationship
between pathway and patient outcomes. An algorithm is a binary
decision tree that guides stepwise assessment and intervention
with intense specificity and no provider flexibility. Guidelines
are broad, research-based practice recommendations that may or
may not have been tested in clinical practice, and an order set is
a preprinted provider order used to expedite the order process
after a practice standard has been validated through analytical
research.
. A nurse uses the following classic elements of evaluation when
caring for patients. Which item below places them in their
correct sequence?
(1) Interpreting and summarizing findings
(2) Collecting data to determine whether evaluative criteria and
standards are met
(3) Documenting one's judgment
(4) Terminating, continuing, or modifying the plan
,(5) Identifying evaluative criteria and standards (what one is
looking for when evaluating, e.g., expected patient outcomes)
1, 2, 3, 4, 5
3, 2, 1, 4, 5
5, 2, 1, 3, 4
2, 3, 1, 4, 5 Correct Answers c. The five classic elements of
evaluation in order are (1) identifying evaluative criteria and
standards (what you are looking for when you evaluate, e.g.,
expected patient outcomes), (2) collecting data to determine
whether these criteria and standards are met, (3) interpreting and
summarizing findings, (4) documenting your judgment, and (5)
terminating, continuing, or modifying the plan.
. When planning care for a patient with chronic lung disease
who is receiving oxygen through a nasal cannula, what does the
nurse expect?
The oxygen must be humidified.
The rate will be no more than 2 to 3 L/min or less.
Arterial blood gases will be drawn every 4 hours to assess flow
rate.
The rate will be 6 L/min or more. Correct Answers . b. A rate
higher than 3 L/min may destroy the hypoxic drive that
stimulates respirations in the medulla in a patient with chronic
lung disease. Oxygen delivered at low rates does not necessarily
have to be humidified, and arterial blood gases are not required
at regular intervals to determine the flow rate.
1. 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.
, The nurse uses the nursing interview to collect patient data.
The nurse analyzes data collected in the nursing assessment.
The nurse develops a care plan for the patient.
The nurse points out the patient's strengths.
The nurse assesses the patient's mental status.
The nurse identifies community resources to help his family
cope. Correct Answers 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.
3. When helping a patient turn in bed, the nurse notices that his
heels are reddened and plans to place him on precautions for
skin breakdown. This is an example of what type of planning?
Initial planning
Standardized planning
Ongoing planning
Discharge planning Correct Answers c. Ongoing planning is
problem oriented and has as its purpose keeping the plan up to
date as new actual or potential problems are identified. Initial
planning addresses each problem listed in the prioritized nursing
diagnoses and identifies appropriate patient goals and the related
nursing care. Standardized care plans are prepared plans of care
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