(NUR 104 )NURSING 104 FINAL EXAM WITH BEST SOLUTION

(NUR 104 )NURSING 104 FINAL EXAM WITH BEST SOLUTIONS The participants of the planning stage of the nursing process during which the health goals are defined include the: - health team, the patient, and the patient's family. When a nurse prioritizes the patient care, consideration is given to: - considering situations that may result in an alteration of health. When a patient states, "I can't walk very well," the first problem-solving step would be to: - find out what the problem is, such as weakness or poor balance. When a resident in the nursing home complains of constipation, the nurse performs a digital rectal examination and finds a hard fecal mass. This is an example of: - assessment. When the nurse checks to see whether a patient has had relief 45 minutes after administering pain medication, the nurse is performing a(n): - evaluation. A nursing care plan consists of: - nursing orders for individualized interventions to assist the patient to meet expected outcomes. A nursing diagnosis consists of: -diagnostic labels formulated by the North American Nursing Diagnosis Association-International (NANDA-I). A patient with visual impairment is identified as at risk for falls related to blindness. An appropriate intervention would be to: - arrange furnishings in room to provide clear pathways and orient the patient to these. An elderly patient with a medical diagnosis of chronic lung disease has developed pneumonia. She is coughing frequently and expectorating thick, sticky secretions. She is very short of breath, even with oxygen running, and she is exhausted and says she "can't breathe." Based on this information, an appropriately worded nursing diagnosis for this patient is - Airway clearance, ineffective, related to lung secretions as evidenced by cough and shortness of breath. During the assessment phase of the nursing process, the nurse - gathers, organizes, and documents data in a logical database. The statements that are correctly stated as expected outcomes are: (Select all that apply.) - Patient will be able to ambulate using a walker independently within 3 days., Patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours. A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is: - Airway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. A nurse will arrive at a nursing diagnosis through the nursing process step of: - assessment. A student nurse can begin to develop critical thinking skills by means of: - listening attentively and focusing on the speaker's words and meaning. An emergency room nurse will give first priority to the patient with the most critical need, which is the patient who: - complains of severe chest pain. Constant nursing assessments and evaluations of the patient will most likely result in: - the nursing care plan changing to reflect appropriate priorities. Descriptions of the activities involved in the nursing diagnosis step of the nursing process are: (Select all that apply.) - determination of potential health problems., clustering of related assessments. In the collaborative process of delivering care based on the nursing process, the responsibility of the LPN/LVN is to: - collect data of health status. Once the nursing plan has been initiated, the nursing care plan will: - change as the patient's condition changes. The activity that is implementation in nursing care is: - changing the patient's surgical dressing. The effect of using a scientific problem-solving approach in nursing care will cause decision making to be: - improved nursing care outcomes. The nurse who uses the nursing process will: - approach the patient's disorder in a step-by-step method. The order in which the nursing process is approached is: - assessment, nursing diagnosis, planning, implementation, evaluation. A nursing care plan consists of: - nursing orders for individualized interventions to assist the patient to meet expected outcomes.