Kozier and Erbs Fundamentals of Nursing – 10th Edition Test Bank

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Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 11
Question 1
Type: MCSA
The student is learning the steps of the nursing process. What is the first thing that the
student should realize about the purpose of this process?
1. Deliver care to a client in an organized way.
2. Implement a plan that is close to the medical model.
3. Identify client needs and deliver care to meet those needs.
4. Make sure that standardized care is available to clients.
Correct Answer: 3
Rationale 1: Delivery of organized care is not part of the nursing process, although
each phase is interrelated.
Rationale 2: The nursing process is not part of the medical model, as nurses treat the
client’s response to the disease or problem.
Rationale 3: The purpose of the nursing process is to identify a client’s health status
and actual or potential health care problems or needs, to establish plans to meet the
identified needs, and to deliver specific nursing interventions to meet those needs.
Rationale 4: The nursing process is individualized for each client’s care plan. It is not
about standardizing care.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Describe the phases of the nursing process.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 155
Question 2
Type: MCSA
While conducting a dressing change, the nurse notes a new area of skin breakdown
that was caused from the tape used to secure the dressing. In which phase of the
nursing process is the nurse working?
1.
2.
3.
4.
Assessment
Diagnosis
Implementation
Evaluation
Correct Answer: 1
Rationale 1: Assessment is the collection, organization, validation, and documentation
of data. Assessment is carried throughout the nursing process, as in this case. Even
though performing the dressing change is implementation, noticing the new skin
breakdown is assessment.
Rationale 2: Diagnosis is identifying the client’s response to the problem.
Implementation is what the nurse does to help the client reach a goal, and then the goal
is evaluated.
Rationale 3: Even though performing the dressing change is implementation, noticing
the new skin breakdown is assessment.
Rationale 4: The goal of the intervention is evaluated, but that is not what is being
described in this scenario.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. Identify the four major activities associated with the assessing
phase.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 159
Question 3
Type: MCSA
During an assessment, a client who is not very talkative appears pale, diaphoretic, and
restless in the bed, and says “leave me alone.” Which subjective data should the nurse
document?
1.
2.
3.
4.
Restlessness
“Leave me alone”
Not talkative
Pale and diaphoretic
Correct Answer: 2
Rationale 1: Restlessness is observable so it is not subjective data.
Rationale 2: Subjective data can be described or verified only by that person and are
apparent only to the person affected. Subjective data include the client’s sensations,
feelings, beliefs, attitudes, and perceptions of personal health status and life situations.
Rationale 3: Not being talkative is observable so it is not subjective data.
Rationale 4: Paleness with diaphoresis is observable so this is not subjective data.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Differentiate objective and subjective data and primary and
secondary data.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 160
Question 4
Type: MCSA
Family of a client demonstrating confusion state that this is not the client’s usual
behavior. How should the nurse document this data?
1.
2.
3.
4.
Inference
Subjective data
Objective data
Secondary subjective data
Correct Answer: 3
Rationale 1: Inference is making a judgment, and that is not what is described in the
question.
Rationale 2: The information provided by the spouse is not subjective because it is an
observation by someone familiar with the client’s usual behavior.
Rationale 3: Information supplied by family members, significant others, or other health
professionals are considered subjective if it is not based on fact. Because this
information is factual, in that the spouse is able to provide the nurse with information
about the client’s routine behavior and patterns, this is objective data.
Rationale 4: The information provided by the spouse is not subjective because it is an
observation by someone familiar with the client’s usual behavior.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Differentiate objective and subjective data and primary and
secondary data.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 160
Question 5
Type: MCSA
The nurse provides a back rub to a client after administering a pain medication with the
hope that these two actions will help decrease the client’s pain. Which phase of the
nursing process is this nurse implementing?
1.
2.
3.
4.
Assessment
Diagnosis
Implementation
Evaluation
Correct Answer: 3
Rationale 1: Assessment is gathering data, and this is not what is described in the
question.
Rationale 2: Diagnosis is identifying patterns and making inferences, and this is not
what is described in the question.
Rationale 3: Implementation is that part of the nursing process in which the nurse
applies knowledge to perform interventions.
Rationale 4: Evaluation is making criterion-based evaluations, and this is not what is
described in the question.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Describe the phases of the nursing process.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase
of the nursing process.
Page Number: 159
Question 6
Type: MCSA
A new client has been admitted to the care area. How soon should the nurse plan to
complete a physical assessment on this patient?
1.
2.
3.
4.
1 hour
12 hours
48 hours
24 hours
Correct Answer: 4
Rationale 1: The Joint Commission requires that each client have an initial assessment
consisting of a history and physical performed and documented within a specific time
period, but not 1 hour.
Rationale 2: The Joint Commission requires that each client have an initial assessment
consisting of a history and physical performed and documented within a specific time
period, but not 12 hours.
Rationale 3: The Joint Commission requires that each client have an initial assessment
consisting of a history and physical performed and documented within a specific time
period, but not 48 hours.
Rationale 4: The Joint Commission requires that each client have an initial assessment
consisting of a history and physical performed and documented within 24 hours of
admission as an inpatient.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10. Contrast various frameworks used for nursing assessment.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 159
Question 7
Type: MCSA
The nurse is admitting an infant to the care area. The parents and grandmother are
present. What should the nurse use as the best source of data for this client?
1.
2.
3.
4.
Medical record from the child’s birth
Grandmother
Parents
Admitting physician
Correct Answer: 3
Rationale 1: The baby’s birth record is able to provide necessary information, but not to
the same extent as the parents.
Rationale 2: Although the grandmother can support the parents during this time and
may be able to offer some helpful information, she would not be the best source.
Rationale 3: The best source of data is usually the client, unless the client is too ill,
young, or confused to communicate clearly. The parents would be able to provide the
nurse with the most accurate, current information regarding the baby (diet, schedule,
symptoms, etc.).
Rationale 4: The admitting physician will be able to provide necessary information, but
not to the same extent as the parents.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6. Identify three methods of data collection, and give examples of
how each is useful.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 161
Question 8
Type: MCSA
A newly admitted client is angry because nursing staff continue to ask the same
questions. What should the nurse respond to this client?
1.
2.
3.
4.
“In order to make sure all of your information is complete, I need to ask these questions.”
“You’re right. Let me know if there’s anything you need right now.”
“I’ll be done shortly, just give me a few more minutes.”
“You shouldn’t be upset. We’re only doing our jobs.”
Correct Answer: 2
Rationale 1: Before asking more questions, the nurse should review what is already at
hand.
Rationale 2: Repeated questioning can be stressful and annoying, especially for
hospitalized clients, and cause concern about the lack of communication among health
professionals. The nurse should review previous records that contain data about the
client’s occupation, religion, and marital status, as well as take time to review all the
information the previous nurse collected. Validating the client’s feelings is always a
good idea and helps to build rapport between the nurse and client.
Rationale 3: This option does not address the client’s legitimate concern, nor does it
acknowledge the client’s feelings.
Rationale 4: Telling the client “we’re only doing our jobs” is belittling to the client and
doesn’t offer a therapeutic response.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 9. Describe important aspects of the interview setting.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 163
Question 9
Type: MCSA
The nurse documents: “Client avoids eye contact and gives only vague, nonspecific
answers to direct questioning by the professional staff. Is quite animated (laughs aloud,
smiles, uses hand gestures) in conversation with spouse.” Which method of data
collection does this documentation demonstrate?
1.
2.
3.
4.
Examining
Interviewing
Listening
Observing
Correct Answer: 4
Rationale 1: Examining is the major method used in the physical health assessment.
Rationale 2: Interviewing is used mainly while taking the nursing health history.
Rationale 3: Listening is only one part of observing.
Rationale 4: Observation is a conscious, deliberate skill that is developed through effort
and with an organized approach. Observation occurs whenever the nurse is in contact
with the client or support persons.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6. Identify three methods of data collection, and give examples of
how each is useful.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 164
Question 10
Type: MCSA
A nurse has worked in the trauma critical care area for several years. Which noise may
become indiscriminate for this particular nurse?
1.
2.
3.
4.
A client with audible breathing
Moaning of a client in pain
Whirring of ventilators
Co-orkers discussing their clients’ conditions
Correct Answer: 3
Rationale 1: Nurses often need to focus on specific data in order not to be
overwhelmed by a multitude of data. Observing involves discriminating data in a
meaningful manner (i.e., noticing things that may indicate cause for concern or action
on the nurse’s part). Listening to a client’s breathing helps the nurse become attentive
to changes in breathing patterns.
Rationale 2: Nurses often need to focus on specific data in order not to be
overwhelmed by a multitude of data. Observing involves discriminating data in a
meaningful manner (i.e., noticing things that may indicate cause for concern or action
on the nurse’s part). A client’s moans of pain should never become easy to listen to.
Rationale 3: The noises of machines and other equipment noises—except alarms—
would be easy to ignore, as these are the usual, normal sounds of the unit.
Rationale 4: Nurses often need to focus on specific data in order not to be
overwhelmed by a multitude of data. Observing involves discriminating data in a
meaningful manner (i.e., noticing things that may indicate cause for concern or action
on the nurse’s part). Listening to coworkers discuss other clients on the unit is helpful in
case the nurse has to attend to any one of them.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10. Contrast various frameworks used for nursing assessment.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 165
Question 11
Type: SEQ
A client has been using the call light routinely throughout the evening. Upon entering the
room, the nurse observes the following details. Organize them according to priority
sequencing (1 is first priority; 5 is least priority).
Standard Text: Click and drag the options below to move them up or down.
Choice 1. The family is at the bedside.
Choice 2. The IV pump is running on battery.
Choice 3. The ECG monitor shows tachycardia.
Choice 4. The client reports being restless.
Choice 5. O2 tubing is not attached to wall regulator.
Correct Answer: 3, 4, 5, 2, 1
Rationale 1: Has no apparent bearing on client’s symptoms
Rationale 2: Indicates an issue worth observing
Rationale 3: Indicates an objective cardiac symptom
Rationale 4: Indicates a subjective symptom
Rationale 5: Indicates a possible cause of the client’s symptoms
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Identify the purpose of assessing.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 164
Question 12
Type: MCSA
During an initial interview, the client says “I don’t understand why I have to have
surgery; I’m really not that sick or in pain right now.” How should the nurse respond to
the client?
1.
2.
3.
4.
“It’s OK to be worried. Surgery is a big step.”
“What kind of questions do you have about your surgery?”
“I think these are things you should be asking your doctor.”
“Have you had surgery before?”
Correct Answer: 2
Rationale 1: Simply noting the concern, without dealing with it, can leave the
impression that the nurse does not care about the client’s concerns or dismisses them
as unimportant.
Rationale 2: The nurse should use a combination of directive and nondirective
approaches during the interview to determine areas of concern for the client.
Rationale 3: Passing the questions off for the doctor would leave the impression that
the nurse does not care about the client’s concerns or dismisses them as unimportant.
Rationale 4: A closed question (Have you had surgery before?) does not allow the
client to offer much information, besides yes/no or one-word answers.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8. Compare closed and open-ended questions, providing examples
and listing advantages and disadvantages of each.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 164
Question 13
Type: MCSA
The nurse is completing a health history with a client who has complications from
chronic asthma. Which open-ended question should the nurse use?
1.
2.
3.
4.
“How would you describe your sleep pattern?”
“Can you describe your coughing pattern?”
“Is there anything that makes your breathing worse?”
“What medications are you on?”
Correct Answer: 1
Rationale 1: Open-ended questions invite clients to discover and explore, elaborate,
clarify, or illustrate their thoughts or feelings. They specify only the broad topic to be
discussed. Open-ended questions invite long answers—longer than one or two words.
Rationale 2: Closed questions can be answered with short, factual, and specific
information.
Rationale 3: Closed questions can be answered with short, factual, and specific
information.
Rationale 4: Closed questions can be answered with short, factual, and specific
information.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8. Compare closed and open-ended questions, providing examples
and listing advantages and disadvantages of each.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 164
Question 14
Type: MCSA
The nurse is assessing a client’s level of pain. Which open-ended question should the
nurse use for this situation?
1.
2.
3.
4.
“Is your pain worse at night?”
“What brought you to the clinic?”
“How has the pain impacted your life?”
“You’re feeling down about having pain, aren’t you?”
Correct Answer: 3
Rationale 1: Closed questions can be answered with one or two words.
Rationale 2: A neutral question is open-ended and is used in nondirective interviews,
which is what would be used if the nurse didn’t understand the reason for the client’s
visit.
Rationale 3: An open-ended question would be beneficial to explore more about the
client’s experience and should be asked with a “how” or “what.”
Rationale 4: A leading question is usually closed and directs the client’s answer (the
nurse stating how the client is feeling, for example).
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8. Compare closed and open-ended questions, providing examples
and listing advantages and disadvantages of each.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 164
Question 15
Type: MCSA
A client is coming in to the clinic for the first time. In order for the nurse to allow the
client the most comfort during the interview, what should the nurse do?
1.
2.
3.
4.
Sit next to the client, a few feet apart.
Sit behind a desk.
Stand at the side of the client’s chair.
Stand at the counter to take notes during the interview.
Correct Answer: 1
Rationale 1: A seating arrangement in which the client and nurse are seated in chairs,
a few feet apart, at right angles to each other and with no table between, creates a less
formal atmosphere, with the nurse and client feeling on equal terms. This would allow
for more comfort and relaxation during the interview phase.
Rationale 2: Sitting behind a desk creates a formal arrangement that suggests a
business meeting between a superior and subordinate.
Rationale 3: Standing and looking down at a client who is in a chair risks intimidating
the client.
Rationale 4: Standing and taking notes infers that the nurse is not really interested in
the client.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 9. Describe important aspects of the interview setting.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 165
Question 16
Type: MCSA
A client in the emergency department has a non-life-threatening wound. The unit is busy
with other clients, families, and people in the waiting room. How should the nurse
conduct an interview with this client?
1.
2.
3.
4.
Have the client wait until the department quiets down, as the wound is not too serious.
Tell the client to wait in the waiting room and fill out the paperwork.
Draw curtains around the client and nurse to provide as much privacy as possible.
Make sure the client’s back is to the rest of the room so as not to be heard by passersby.
Correct Answer: 3
Rationale 1: Having the client wait may cause an unnecessary delay in treatment.
Rationale 2: Having the client wait and fill out paperwork may cause an unnecessary
delay in treatment.
Rationale 3: The interview setting should be in a well-lighted, well-ventilated room that
is relatively free of noise, movements, and distractions in order to encourage
communication. The interview should also take place in an area where others cannot
overhear or see the client if possible. In this situation, at least pulling a privacy curtain
will help keep the client from view of others in the department.
Rationale 4: Making sure the client’s back is to the rest of the room is not acceptable.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7. Compare directive and nondirective approaches to interviewing.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 165
Question 17
Type: MCSA
A client has been admitted for acute dehydration, secondary to nausea and diarrhea.
When is the best time for the nurse to conduct this client’s interview?
1.
2.
3.
4.
As soon as the client gets to the floor
After the client has settled in and been oriented to the room
When the family is available to help
After the client has been medicated
Correct Answer: 2
Rationale 1: Interviews should be planned when the client is physically comfortable and
free of pain, and when interruptions by the family are minimal.
Rationale 2: After the client has been oriented to the bathroom and nurse call light, the
nurse should start the interview process. In this situation, the nurse may have to pace
the interview according to the client’s comfort level.
Rationale 3: Interviews should be planned when the client is physically comfortable and
free of pain, and when interruptions by the family are minimal.
Rationale 4: Medication may affect the client’s ability to think clearly, so getting as
much information as quickly as possible is important.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9. Describe important aspects of the interview setting.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 165
Question 18
Type: MCSA
A nurse has been assigned a new client who cannot speak English. How should the
nurse facilitate communication with this client?
1. Have a member of the housekeeping staff who speaks the same language translate.
2. Use the translation services supplied by the hospital.
3. Make sure a family member who does speak English is available.
4. Conduct the interview using hand gestures.
Correct Answer: 2
Rationale 1: Nurses must be cautious when asking family members, client visitors, or
agency nonprofessional staff to assist with translation. Issues of confidentiality or
gender mismatch can interfere with effective communication.
Rationale 2: Live translation is preferred because the client can then ask questions for
clarification. Many large facilities are establishing their own translator services for the
languages commonly spoken in their geographical regions.
Rationale 3: Nurses must be cautious when asking family members, client visitors, or
agency nonprofessional staff to assist with translation. Issues of confidentiality or
gender mismatch can interfere with effective communication.
Rationale 4: Using hand gestures is not an appropriate way to communicate with a
client when other options are available.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Identify three methods of data collection, and give examples of
how each is useful.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 166
Question 19
Type: MCSA
The nurse is greeting a newly admitted client. What statement should the nurse make to
establish rapport with this client?
1.
2.
3.
4.
“Hello, I’m your nurse and I’ll be taking care of you today.”
“You’re lucky—there are no students on the unit today.”
“Good morning, is there anything you need right now?”
“Hi. If you need anything, put on your call light.”
Correct Answer: 1
Rationale 1: Establishing rapport is a process of creating goodwill and trust and usually
begins with a greeting and self-introduction, accompanied by nonverbal gestures such
as a smile, a handshake, and a friendly manner. Making introductions, especially
offering the use of name, is especially good in establishing rapport.
Rationale 2: Telling a hospitalized client he or she is lucky is probably not the best
therapeutic comment.
Rationale 3: Establishing rapport is a process of creating goodwill and trust and usually
begins with a greeting and self-introduction, accompanied by nonverbal gestures such
as a smile, a handshake, and a friendly manner.
Rationale 4: Establishing rapport is a process of creating goodwill and trust and usually
begins with a greeting and self-introduction, accompanied by nonverbal gestures such
as a smile, a handshake, and a friendly manner.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Identify three methods of data collection, and give examples of
how each is useful.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 166
Question 20
Type: MCSA
The nurse has just completed an admission interview with a new client. Which nursing
statement indicates that the interview is in the closing phase?
1.
2.
3.
4.
“I’m going to set up your physical assessment now. Do you have any questions?”
“Tell me more about how you feel.”
“Could you give examples of what types of other treatments you’ve had?”
“Is there anything you’re worried about?”
Correct Answer: 1
Rationale 1: Closing the interview is important for maintaining the rapport and trust
between the client and nurse as well as to facilitate future interactions. The closing
should contain an offer for questions, conclusions, plans for the next meeting, and a
summary to verify accuracy.
Rationale 2: This would be part of the body of the interview—questions designed to
gather the most information about the situation.
Rationale 3: This would be part of the body of the interview—questions designed to
gather the most information about the situation.
Rationale 4: This would be part of the body of the interview—questions designed to
gather the most information about the situation.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Identify three methods of data collection, and give examples of
how each is useful.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 167
Question 21
Type: MCSA
During an assessment interview, the client states that an elective surgical procedure will
not be done because it does not fit into the client’s life goals. Into which of Gordon’s
functional health patterns should the nurse identify this client’s comment?
1. Cognitive/perceptual pattern
2. Coping/stress-tolerance pattern
3. Health-perception/health-management pattern
4. Value/belief pattern
Correct Answer: 4
Rationale 1: Cognitive perceptual patterns describe sensory-perceptual and cognitive
patterns.
Rationale 2: Coping/stress-tolerance patterns describe the client’s general coping
pattern and the effectiveness of the patterns in terms of stress tolerance.
Rationale 3: Health-perception/health-management pattern describes the client’s
perceived pattern of health and well-being and how health is managed.
Rationale 4: The value/belief pattern describes the patterns of values, beliefs (including
spiritual), and goals that guide the client’s choices or decisions. The client in this
situation has decided against a surgical procedure because it doesn’t coincide with the
client’s beliefs and goals.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 10. Contrast various frameworks used for nursing assessment.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 170
Question 22
Type: MCSA
The nurse suspects that a client with a history of injuries is a victim of abuse. What did
the nurse use to come to this conclusion?
1.
2.
3.
4.
Observation of cues
Validation
Inference
Judgment
Correct Answer: 3
Rationale 1: Cues are subjective or objective data that can be directly observed by the
nurse.
Rationale 2: Validation is the act of “double-checking” or verifying data to confirm that
they are accurate and factual.
Rationale 3: Inferences are the nurse’s interpretations of conclusions made based on
the cues, which in this case would be the frequent visits to the emergency department
and the client’s injuries. Data must be based on cues, and the nurse must be careful not
to jump to conclusions.
Rationale 4: Judgment is not part of validation.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 7. Compare directive and nondirective approaches to interviewing.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 172
Question 23
Type: MCMA
The nurse is reviewing the nursing process with a first-year nursing student. What
should the nurse explain as being the purpose of the diagnosis phase?
Standard Text: Select all that apply.
1.
2.
3.
4.
5.
Develop a list of problems.
Identify client strengths.
Develop a plan.
Specify goals and outcomes.
Identify problems that can be prevented.
Correct Answer: 1, 2, 5
Rationale 1: Diagnosing is analyzing and synthesizing data in order to identify client
strengths and health problems that can be prevented or resolved by collaborative and
independent nursing interventions as well as developing a list of nursing and
collaborative problems.
Rationale 2: Diagnosing is analyzing and synthesizing data in order to identify client
strengths and health problems that can be prevented or resolved by collaborative and
independent nursing interventions as well as developing a list of nursing and
collaborative problems.
Rationale 3: Developing a plan is part of the planning phase.
Rationale 4: Specifying goals and outcomes is part of the planning phase.
Rationale 5: Diagnosing is analyzing and synthesizing data in order to identify client
strengths and health problems that can be prevented or resolved by collaborative and
independent nursing interventions as well as developing a list of nursing and
collaborative problems.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 1. Describe the phases of the nursing process.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the
nursing process.
Page Number: 156
Question 24
Type: MCSA
The nurse decides to seek wound care alternatives for a client’s stasis ulcer that is not
healing after treatment for 2 weeks. In which phase of the nursing process is the nurse
functioning?
1.
2.
3.
4.
Diagnosis
Implementation
Evaluation
Assessment
Correct Answer: 3
Rationale 1: Diagnosis is problem identification.
Rationale 2: Implementation is carrying out (or delegating) the planned nursing
interventions. Wound care would be the implementation of this particular case.
Rationale 3: Evaluation is measuring the degree to which goals/outcomes have been
achieved and identifying factors that positively or negatively influence goal achievement.
Activities of evaluation include judging whether goals/outcomes have been achieved
and making decisions about problem status. The client’s wound is not healing and the
nurse decides to modify the nursing interventions.
Rationale 4: Assessment is collecting and organizing data.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1. Describe the phases of the nursing process.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in
the care of the client.
Page Number: 156
Question 25
Type: MCSA
While preparing a client for a procedure, the nurse notes that the client has become
unresponsive and respirations have become shallow. What type of assessment should
the nurse complete at this time?
1.
2.
3.
4.
Initial assessment
Problem-focused assessment
Emergency assessment
Time-lapsed assessment
Correct Answer: 3
Rationale 1: Initial assessment is performed within a specific time after admission to a
health care agency.
Rationale 2: Problem-focused assessment is an ongoing process integrated with
nursing care.
Rationale 3: An emergency assessment is performed during any physiologic or
psychologic crisis of the client to identify life-threatening problems.
Rationale 4: Time-lapsed assessment occurs several months after the initial
assessment to compare the client’s current status to baseline data previously obtained.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Differentiate objective and subjective data and primary and
secondary data.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 161
Question 26
Type: MCSA
Unlicensed assistive personnel measure a newly admitted client’s vital signs to be:
temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure =
200/146. What should the nurse do to validate this data?
1.
2.
3.
4.
Retake the vital signs.
Call the physician.
Continue with the physical assessment as soon as possible.
Report the findings to the charge nurse.
Correct Answer: 1
Rationale 1: Guidelines for validating assessment data that are out of normal range
include repeating the measurements, using another piece of equipment as needed to
confirm abnormalities, or asking someone else to collect the same data. In this situation,
the nurse needs to be sure that the vital signs are accurate.
Rationale 2: Calling the physician would be premature.
Rationale 3: The physical assessment should be done as soon as possible anyway, but
not until after the vital signs have been validated.
Rationale 4: Reporting the findings to the charge nurse before they have been
validated would be premature.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Differentiate objective and subjective data and primary and
secondary data.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 171
Question 27
Type: MCMA
A nurse is performing an initial assessment on a new admission. What information
should the nurse consider as being a part of the database?
Standard Text: Select all that apply.
1.
2.
3.
4.
5.
6.
Reports from physical therapy the client received as an outpatient
Documentation of the nurse’s physical assessment
Physician’s orders
A list of current medications
Information about the client’s cultural preferences
Discharge instructions
Correct Answer: 1, 2, 4, 5
Rationale 1: The database is all the information about a client. It includes the nursing
health history, physical assessment, the physician’s history and physical examination,
results of laboratory and diagnostic tests, and material contributed by other health
personnel.
Rationale 2: The database is all the information about a client. It includes the nursing
health history, physical assessment, the physician’s history and physical examination,
results of laboratory and diagnostic tests, and material contributed by other health
personnel.
Rationale 3: The database is all the information about a client. It includes the nursing
health history, physical assessment, the physician’s history and physical examination,
results of laboratory and diagnostic tests, and material contributed by other health
personnel. It would not include the physician’s orders for this admission, or discharge
instructions.
Rationale 4: The database is all the information about a client. It includes the nursing
health history, physical assessment, the physician’s history and physical examination,
results of laboratory and diagnostic tests, and material contributed by other health
personnel. Current medications would be a part of this database.
Rationale 5: The database is all the information about a client. It includes the nursing
health history, physical assessment, cultural preferences, the physician’s history and
physical examination, results of laboratory and diagnostic tests, and material
contributed by other health personnel.
Rationale 6: The database is all the information about a client. It includes the nursing
health history, physical assessment, the physician’s history and physical examination,
results of laboratory and diagnostic tests, and material contributed by other health
personnel. It would not include discharge instructions.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6. Identify three methods of data collection, and give examples of
how each is useful.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 160
Question 28
Type: MCMA
The nurse is conducting an interview with a new client. Which actions indicate that the
nurse is implementing effective communication guidelines?
Standard Text: Select all that apply.
1.
2.
3.
4.
5.
Looking directly at the client to ensure good eye contact
Managing the conversation to avoid periods of silence
Providing personal experiences to help the client focus
Sitting in a chair next to the client who is in bed
Keeping arms unfolded and in a relaxed position
Correct Answer: 1, 4, 5
Rationale 1: Communication guidelines for a therapeutic interview would include
establishing eye contact, as doing so shows interest and a focus on the client.
Rationale 2: Communication guidelines for a therapeutic interview would not include
the avoidance of silence, as silence has therapeutic value.
Rationale 3: Communication guidelines for a therapeutic interview would not include
personal experiences or opinions, as they can be viewed as a form of pressure by the
client.
Rationale 4: Communication guidelines for a therapeutic interview would include sitting
at the client’s eye level, as doing so helps create a sense of equality between the nurse
and client.
Rationale 5: Communication guidelines for a therapeutic interview would include
assuming a relaxed posture, as doing so conveys a nonthreatening environment.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9. Describe important aspects of the interview setting..
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 165
Question 29
Type: MCMA
The nurse manager observes a staff nurse perform actions within the nursing process.
Which activities did the manager observe the nurse perform?
Standard Text: Select all that apply.
1. Notifying the surgeon that a postoperative client is experiencing an increase in
temperature
2. Advocating for a client who is mentally incapable of expressing her needs
3. Deciding to increase a client’s nasal oxygen based on his current pulse oxygenation
levels
4. Documenting all clients’ pain level responses after the administration of pain medication
5. Attending in-services on a new hydraulic lift to be used to support safe client care
Correct Answer: 1, 2, 3, 4
Rationale 1: The nursing process has distinctive characteristics that include being
dynamic so as to respond to clients’ ever-changing needs.
Rationale 2: The nursing process has distinctive characteristics that include being
client-centered, as evidenced by actions such as acting as the client’s advocate.
Rationale 3: The nursing process has distinctive characteristics that include decision
making that enables the nurse to respond to the changing health status of the client.
Rationale 4: The nursing process has distinctive characteristics that include universal
applicability of care.
Rationale 5: This is a nursing responsibility but not necessarily a characteristic of the
nursing process.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 02 Identify major characteristics of the nursing process.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 2. Identify major characteristics of the nursing process.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 158
New Questions:
Question 30
Type: MCMA
The nurse is completing a health history with a newly admitted client. What information
should the nurse include when asking about the history of the client’s present illness?
Standard text: Select all that apply.
1.
2.
3.
4.
5.
Allergies
Immunization record
When the symptoms started
Exact location of the problem
Things that aggravate the problem
Correct Answer: 3, 4, 5
Rationale 1: Allergies is a part of the past history.
Rationale 2: Immunization record is a part of the past history.
Rationale 3: When the symptoms started is a part of the history of present illness.
Rationale 4: The location of the problem is a part of the history of present illness.
Rationale 5: Things that aggravate the problem is a part of the history of present
illness.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10. Contrast various frameworks used for nursing assessment.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 162
Question 31
Type: MCMA
The nurse manager observes a new graduate nurse complete assessment activities for
a newly admitted client. Which actions indicate that the graduate needs assistance with
the assessment process?
Standard Text: Select all that apply.
1.
2.
3.
4.
5.
Reviews client record
Establishes a database
Performs nursing actions
Reviews nursing literature
Determines client’s strengths, risks, and problems
Correct Answer: 3, 5
Rationale 1: Reviewing client records is a part of the assessment phase of the nursing
process.
Rationale 2: Establishing a database is a part of the assessment phase of the nursing
process.
Rationale 3: Performing nursing actions is a part of the implementation phase of the
nursing process.
Rationale 4: Reviewing nursing literature is a part of the assessment phase of the
nursing process.
Rationale 5: Determining the client’s strengths, risks, and problems is a part of the
diagnosis phase of the nursing process.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient
centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical,
behavioral, psychological, spiritual, socioeconomic, and environmental assessments of
health and illness parameters in patients, using developmentally and culturally
appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based
transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4. Identify the four major activities associated with the assessing
phase.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of
the nursing process.
Page Number: 158
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