Question 1

The nurse is providing care to an assigned client.Which action indicates that the nurse supports the client's respect for dignity?

Accepted Answer

Allowing the client to complete hygienic care when possible respects the client's dignity by promoting independence and autonomy. It recognizes that clients have the right to make decisions about their own care and promotes their self-esteem and sense of control. Providing all care to the client whenever possible may not necessarily respect the client's dignity, as it may foster dependence and diminish the client's sense of control. Telling other staff that the client is demanding does not respect the client's dignity, as it diminishes the client's standing in the eyes of others. Presenting information to the client's family about the client's condition may or may not respect the client's dignity, depending on the circumstances.

Question 2

A client has neurologic deficits that are causing tremors,unsteadiness,and weakness.An appropriate diagnosis of Risk for Falls related to unsteady gait,secondary to neurologic dysfunction has been formulated.A goal for this client is not to sustain any injuries for the next month;however,the client has fallen several times.In this situation,what should the nurse do?

Accepted Answer

If the client has fallen several times despite the nursing interventions, it may be necessary to investigate whether the best interventions were selected or if modifications are needed to prevent further falls. Reviewing the data and making sure the diagnosis is relevant may be a step in this process, but it is not the most appropriate action in this situation. Modifying the whole nursing plan or discarding it and starting over from the assessment phase may also be unnecessary and time-consuming. Therefore, the best choice is to investigate whether the best nursing interventions were selected.

Question 3

A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." What statement demonstrates that the nurse appropriately evaluated this goal?

Accepted Answer

The nurse appropriately evaluated the goal statement as "goal met" as the client was able to state two positive aspects of rehab therapy by the end of the week.

Question 4

On one of the first days working alone,the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse.What action should the nurse take?

Accepted Answer

The new nurse should recognize their limitations and seek assistance from their mentor to ensure that the teaching is done correctly and safely. Having the mentor review the procedure before the teaching session will also help the nurse gain more knowledge and confidence.

Question 5

A teenage client has been having problems with peer support,school performance,and parental expectations,all of which contributed to an eating disorder.After gathering this assessment data,the nurse formulates the diagnosis Activity Intolerance related to weakness.What should the nurse realize after evaluating this diagnosis?

Accepted Answer

The diagnosis of activity intolerance related to weakness does not seem to be supported by the assessment data provided. There is no indication that the client is experiencing physical weakness as a result of their eating disorder or any other medical condition. Therefore, the data are not sufficient to support this diagnosis. The nurse should choose a different diagnosis that aligns with the client's actual symptoms and concerns.

Question 6

The home health nurse uses creativity and critical thinking to devise a way for a client to receive intravenous medication while sitting outside on the porch.Which skill did the nurse use for this situation?

Accepted Answer

The nurse used cognitive skills, which involve critical thinking and problem-solving to devise a solution for administering medication in a non-traditional setting.

Question 7

A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process.The goal statement is as follows: Client will be free of pain within 48 hours.As an intervention,the nurse will administer narcotic analgesics and titrate to an appropriate level.What is the flaw in this plan?

Accepted Answer

The goal statement of being free of pain within 48 hours is unrealistic for a client with terminal cancer. It is important to manage pain effectively, but complete relief may not be achievable in this situation. A more realistic goal may be to reduce the intensity of pain to a manageable level or increase the client's comfort.

Question 8

A care area has been short staffed for the past month with a heavy client load and high acuity.The nurses have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned,returned,and stored in the appropriate areas.At what level should this care area be evaluated?

Accepted Answer

The scenario describes issues related to the structure of the care area, such as staffing levels and availability of properly working equipment, which directly impact the ability to provide care.

Question 9

The nurse manager has been appointed to implement a quality assurance program at the hospital.Which components should the manager prepare to evaluate for this program?

Accepted Answer

The components that should be evaluated for a quality assurance program include structure (the physical and organizational resources), process (the steps taken during care delivery), and outcomes (the resulting patient outcomes). Finances (C) may be indirectly evaluated as part of the structure component, but it is not a specific component to be evaluated. Methods (A) may be a part of the process component, but it is not a specific component to be evaluated separately. Therefore, the best choices are B, D, E.

Question 10

A client has the goal statement "Client will have clear lung sounds bilaterally within 3 days." One intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have the client do this several times every 2 hours.At the end of the third day,the client's lungs are indeed clear.What should the nurse do to relate the intervention to the outcome?

Accepted Answer

The answer of A client has the goal statement "Client...

Question 11

The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior.Which skill should the nurse use when caring for these clients?

Accepted Answer

Interpersonal skills are essential for nurses caring for clients with paranoid behavior, as they involve establishing rapport, building trust, and communicating effectively to reduce anxiety and promote a sense of safety.

Question 12

Upon entering a room,a client and spouse are found crying.The nurse decides to sit with both of them,offering presence and listening to their fears instead of providing the planned education.What action did the nurse perform?

Accepted Answer

The answer of Upon entering a room,a client and spouse...

Question 13

During teaching,the nurse makes sure the client understands how to activate the safety mechanism on the syringe to prevent needlestick injuries when self-administering insulin.Which guideline of implementing interventions is the nurse using?

Accepted Answer

The nurse is implementing safe care by teaching the client how to activate the safety mechanism on the syringe to prevent needlestick injuries.

Question 14

A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss,secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago.A goal was that the client's symptoms would be eliminated within 48 hours.The client is being seen after a week,and has had no diarrhea or vomiting for the past 5 days.What should the nurse do?

Accepted Answer

The goal of eliminating the client's symptoms within 48 hours has been met, as the client has not had diarrhea or vomiting for the past 5 days. Therefore, the nurse should document that the problem has been resolved and discontinue the care for the problem. Keeping the problem on the care plan or assuming that the symptoms may return, while also documenting that the goal was met, are not necessary or appropriate given the situation. Documenting that the potential problem is being prevented because the symptoms have stopped is also not the best answer, as the focus should be on resolving the problem that was initially identified.

Question 15

A home care client must correctly self-administer insulin injections before being discharged from the agency.On what skill is this client being evaluated?

Accepted Answer

The client is being evaluated on their technical skill, which involves the ability to perform a specific task, such as self-administering insulin injections correctly.

Question 16

The nurse is caring for a new mother and infant.Which action should the nurse take that allows the new parents to feel in control when being taught how to bathe their infant?

Accepted Answer

Allowing the parents to bathe the baby with direction and guidance from the nurse empowers them in the care of their infant and allows them to feel in control. Giving too much advice and suggestions can be overwhelming for new parents, and simply watching a video may not give them the hands-on experience they need to feel confident in bathing their baby. Telling the parents everything the nurse is doing and why can be helpful, but it may not give the parents the opportunity to actively participate in the care of their newborn.

Question 17

The nurse is preparing to provide care planned for a client.What actions should the nurse complete during this phase of client care?

Accepted Answer

The answer of The nurse is preparing to provide care...

Question 18

The nurse provides routine morning care to a client,including all the medications and scheduled treatments.What action should the nurse make next?

Accepted Answer

It is important for the nurse to document all care provided in the progress notes to ensure continuity of care and accurate information for other healthcare team members. This will also serve as a legal document if needed. While organizing supplies for the next client is important, it should not take priority over documenting care provided. Reporting to the charge nurse may be appropriate if there were any issues or concerns during the morning care, but it is not necessarily the next action the nurse needs to take. Moving on to the next assignment without completing documentation could result in incomplete or inaccurate information being passed on to other healthcare team members, which could negatively impact the client's care.

Question 19

A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual.What should the nurse do?

Accepted Answer

It is important for the nurse to have complete knowledge about the medication before administering it. As there is no information available in the drug reference manual, the nurse should call the pharmacy or do further investigation before giving the medication to the client. This will ensure that the medication is appropriate for the client and given in the correct manner.

Question 20

The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse.What should the nurse emphasize as the major difference between these two steps in the nursing process?

Accepted Answer

Assessment involves collecting data to understand the patient's condition, while evaluation involves analyzing the data to determine if the patient's goals have been met.

Quiz 14: Implementing and Evaluating