Question 1

A client exhibits signs of stress while awaiting results of lab work,and a nursing diagnosis of Anxiety secondary to knowledge deficit is made.Which type of nursing diagnosis does this represent?

Accepted Answer

In an actual diagnosis,such as Self-care deficit,feeding R/T loss of function of right arm,the problem exists and there are signs and symptoms of the problem present.

Question 2

The nurse uses an assessment model that is derived from Maslow's theory.This model is based upon:

Accepted Answer

Maslow's hierarchy of needs consists of five levels: physiologic,safety and security,love and belonging,self-esteem,and self-actualization.The essence of the theory is that a person's needs can be illustrated in a pyramid with the lowest-level needs forming its base.Subsequent-level needs are built upon this base,forming a hierarchical arrangement.A person's lowest-level needs must be met before the person is motivated to achieve the next level of needs;higher-level needs contribute to the individual's quality of life.

Question 3

Which of the following is a primary source of client data?

Accepted Answer

Data is collected from a variety of sources,but the client is considered the primary source of data as the major provider of information.As much information as possible should be gathered from the client,using both interview and physical assessment skills.

Question 4

The nurse is unable to obtain information from the client and knows the BEST secondary source of client information is which of the following?

Accepted Answer

Secondary sources are considered to be family members,other health care providers,and medical records.

Question 5

A facility's admission database divides client data by body systems and includes a section on psychosocial aspects of client status.This type of grouping similar data together into categories is called:

Accepted Answer

Data obtained from the client is organized into categories and clustered to identify areas of strength and weakness.

Question 6

A client has been admitted with a history of dizzy spells and nausea.The client's blood pressure is highly variable with an elevated temperature on 3 successive days.The physician has ordered vital-sign monitoring,including temperature,heart rate,respirations,and blood pressure every 4 hours.What type of assessment is this type of monitoring called?

Accepted Answer

Ongoing assessment is done to confirm the validity of initial assessment data or to expand the original database;it includes systematic monitoring and observation of identified health problems,response to a plan of care that has been implemented,and identification of any new problems.Data collected during assessment are either subjective (obtained from the client's perspective,including feelings,perceptions,and concerns)or objective (observable and measurable).The client's health history (a review of functional health patterns prior to the current contact with the health care provider)comprises subjective data obtained primarily by interview.Objective data are obtained through standard assessment techniques performed during the client's physical examination and from any laboratory and diagnostic testing.

Question 7

When client data are broken down into parts that can be examined,which step of the nursing process is involved?

Accepted Answer

Nursing diagnosis,the second step of the nursing process,involves the analysis and synthesis of data gathered during the assessment phase to represent a clinical judgment about a client's responses to actual or potential health problems or life processes.

Question 8

During an initial assessment,the nurse notes that the client reports being unable to walk more than a few steps without becoming short of breath.Which of these functional health patterns needs further investigation?

Accepted Answer

Functional health patterns (e.g. ,health perception/management,nutritional/metabolic,elimination,activity/exercise,cognitive/perceptual,sleep/rest,self-perception/self-concept,role/relationship,sexuality/reproduction,coping/stress-tolerance,and value/belief)organize client data to determine if a client's current health patterns are working or not working.

Question 9

A client has a nursing diagnosis of Readiness for enhanced spiritual well-being.Which type of nursing diagnosis does this represent?

Accepted Answer

A wellness diagnosis,such as Health-seeking behaviors R/T desire for increased physical endurance.A nursing diagnosis focuses on a client's response to enhance current health status or prevent potential health problems or life processes.

Question 10

The nurse uses this type of assessment and organizes client data to determine if a client's current health patterns are working or not working:

Accepted Answer

Functional health patterns (e.g. ,health perception/management,nutritional/metabolic,elimination,activity/exercise,cognitive/perceptual,sleep/rest,self-perception/self-concept,role/relationship,sexuality/reproduction,coping/stress-tolerance,and value/belief)organize client data to determine if a client's current health patterns are working or not working.

Question 11

A nurse is completing a client's initial admission database by asking the client questions about his past and current state of health,family history,and physical exam.These actions are part of which step of the nursing process?

Accepted Answer

The purpose of assessment is to establish a database about a client.Data about a client's physical,psychological,and emotional health are necessary to identify the client's health-promoting behavior and actual or potential health problems.To obtain these data,a nurse determines such things as the client's functional abilities,the normal activities of daily living,and lifestyle patterns.From these data,the nurse can identify client strengths and limitations that can affect treatment and recovery.

Question 12

Which of the following would a nurse expect to include in the assessment phase of the nursing process?

Accepted Answer

The purpose of assessment is to establish a database about a client.Data about a client's physical,psychological,and emotional health are necessary to identify the client's health-promoting behavior and actual or potential health problems.To obtain these data,a nurse determines such things as the client's functional abilities,the normal activities of daily living,and lifestyle patterns.From these data,the nurse can identify client strengths and limitations that can affect treatment and recovery.

Question 13

A client has suffered a mild stroke.Which type of nursing diagnosis would reflect the client's health status?

Accepted Answer

Nursing diagnoses can be classified as actual diagnoses,such as Self-care deficit,feeding R/T loss of function of right arm.In an actual diagnosis,the problem exists and there are signs and symptoms of the problem present.

Question 14

A client's hospital admission assessment includes a health history and current health assessment.This type of assessment is known as:

Accepted Answer

Comprehensive assessment,which is usually completed when a client is admitted for health care services,includes a complete client health history and current needs assessment and provides baseline data against which changes in health status can be compared.Assessment of the client's physical and psychological health,the client's perception of health,any health risk factors,and the client's coping patterns is part of a comprehensive assessment.

Question 15

How does a nursing diagnosis differ from a medical diagnosis?

Accepted Answer

Nursing diagnosis,the second step of the nursing process,involves the analysis and synthesis of data gathered during the assessment phase to represent a clinical judgment about a client's responses to actual or potential health problems or life processes.A nursing diagnosis provides the basis for choosing nursing interventions to achieve desired client outcomes.

Question 16

Which of these provide the basis for selecting nursing interventions to achieve the goals for which the nurse is accountable?

Accepted Answer

By using the nursing process,nurses can apply a systematic thought process to client situations to make the best possible decisions about what the client needs and how these needs can be achieved.The process also helps nurses analyze situations and communicate effectively with a client's family members and other members of the health care team.The steps of the nursing process are dynamic and include assessment,diagnosis,planning and outcome identification,implementation,and evaluation.

Question 17

When a nurse puts data together in a new way,the process is called:

Accepted Answer

Synthesis involves putting data collected together in a new way.

Question 18

A client reports leg pain when walking or standing,and occasional pain during periods of rest.This type of data is known as:

Accepted Answer

Subjective data is data from the client's point of view and include perceptions,feelings,and concerns.

Question 19

The nurse performs an initial assessment of a client's physiologic needs followed by assessment of higher-level needs.This is an example of:

Accepted Answer

Maslow's hierarchy of needs consists of five levels: physiologic,safety and security,love and belonging,self-esteem,and self-actualization.The essence of the theory is that a person's needs can be illustrated in a pyramid with the lowest-level needs forming its base.Subsequent-level needs are built upon this base,forming a hierarchical arrangement.A person's lowest-level needs must be met before the person is motivated to achieve the next level of needs;higher-level needs contribute to the individual's quality of life.

Question 20

The nurse is gathering data about the client through physical examination and observation.This is an example of:

Accepted Answer

Objective data is gained through physical examination and observation of clients.Objective data is observable and measurable.

Quiz 9: Nursing Processdocumentationinformatics