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NS 332 Fundamentals Exam II Questions With Complete Solutions
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NS 332 Fundamentals Exam II Questions With Complete Solutions
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NS 332 Fundamentals Exam II Questions With CompleteSolutions
"The levels of performance accepted by and expected of nursing
staff or other health team members" defines: Correct Answers
standards.
Standards are the "levels of performance accepted by and
expected of nursing staff or other health team members."
Criteria are "measurable qualities, attributes, or characteristics
that identify skill, knowledge, or health status." Evidence-based
practice incorporates delivering nursing care that evidence
supports as likely to result in meeting the expected client
outcomes. Evaluation involves measuring how well the client
has achieved the outcomes that were set forth in the plan of care.
A _____________ of nursing practice is established by
authority, custom, or consent, and reflects a level of
performance accepted by and expected of nursing staff. Correct
Answers standard
A _____________ or a norm is a generally accepted rule,
measure, pattern, or model to which data can be compared in the
same class or category. Correct Answers standard
A _________________ nursing diagnosis/patient problem
statement is a clinical judgment concerning an undesirable
human response to a health condition/life process that exists in
an individual, family, group, or community. Correct Answers
problem-focused
,A ________-initiated intervention is an autonomous action
based on scientific rationale that a nurse executes to benefit the
patient in a predictable way. Correct Answers nurse
A client reports not having a bowel movement for 7 days,
followed by a day of small, loose stools. How does the nurse
define the health problem? Correct Answers Constipation
related to irregular evacuation patterns
A client's diagnosis of breast cancer necessitates a bilateral
mastectomy and breast reconstruction with tissue expanders.
The nurse recognizes that the client's surgery will have a
significant impact on the client's activities of daily living
(ADLs) during the period of recovery. When should the nurse
begin discharge planning to address this client's ADLs? Correct
Answers On the client's admission to the hospital
A data ____________ is a grouping of patient data or cues that
point to the existence of a patient health problem. Correct
Answers cluster
A new mother is having difficulty breastfeeding a newborn. A
goal was established stating that the infant would be nursing
every 2 to 3 hours by age 1 week. The mother presents to the
follow-up center at 1 week and reports having discontinued
breastfeeding 4 days ago. The nurse evaluates the original goal
as: Correct Answers completely unmet.
After collecting data and evaluating the client's behavioral
responses, the nurse makes a judgment about goal attainment by
comparing the client's actual behavioral responses with the
,predicted responses or predetermined outcome criteria
developed in the planning phase. In this case the mother
abandoned breastfeeding, which represents a complete failure to
meet the collaborative goal established. If the mother reported
breastfeeding the infant every 4 to 5 hours, the nurse could
consider the goal partially met. There is no evidence that the
goal was inappropriately chosen for the client.
A nurse develops a care plan for an adolescent patient who gave
birth to a premature infant. When presented with the
collaborative care plan, including home health care visits, the
patient states, "We will be fine on our own. I don't need any
more care." What is the nurse's best response?
a. "You know your personal situation better than I do; I will
respect your wishes."
b. "If you don't accept these services, your baby's health will
suffer."
c. "Let's take a look at the plan again and see if we can adjust it
to fit your needs."
d. "I'm going to assign your case to a social worker who can
explain the services better." Correct Answers c. When a patient
rejects the care plan, the nurse works to identify the underlying
barriers. If the nurse determines that the care plan is adequate,
the nurse works with the patient to formulate mutually
developed goals and interventions.
A nurse enters the patient's room to perform pin-site care for a
patient wearing a halo vest to stabilize the cervical spine. What
action will the nurse take first?
, a. Administer pain medication
b. Reassess the patient
c. Prepare the equipment
d. Explain the procedure to the patient Correct Answers b.
Before implementing any nursing action, the nurse returns to the
first step of the nursing process, reassessing whether the action
is still needed. Then the nurse may collect the equipment,
explain the procedure, and, if necessary, administer pain
medications.
A nurse has performed an admission assessment on a patient.
What step does the nurse perform after clustering the data?
a. Developing interventions
b. Nursing judgments
c. Diagnosing and analyzing
d. Concept mapping Correct Answers c. After clustering the
data, the nurse analyzes the data and formulates a nursing
diagnosis. Interventions are based on and developed after goal
setting. Nursing judgments are outcomes based on critical
thinking and clinical reasoning. A concept map is a diagram or
pictorial representation of the (student) nurse's understanding of
the interactions and relationships of the patient's problems and
plan of care.
A nurse in the emergency department is assessing a young adult
who has cognitive disability and is reporting severe abdominal
pain. The patient is accompanied by the director of the group
home where they live. When collecting data from this patient,
which action reflects best practice?
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