NURS 200 Final Exam Chap 11 Question 1 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?
- Deliver care to a client in an organized way.
- Implement a plan that is close to the medical model.
- Identify client needs and deliver care to meet those needs.
- Make sure that standardized care is available to clients.
Correct Answer: 3
Question 2 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?
- Assessment
- Diagnosis
- Implementation
- Evaluation
Correct Answer: 1
Question 3 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?
- Restlessness
- Leave me alone
- Not talkative
- Pale and diaphoretic
Correct Answer: 2
Question 4 1 / 4
Family of a client demonstrating confusion state that this is not the clients usual behavior. How should the nurse document this data?
- Inference
- Subjective data
- Objective data
- Secondary subjective data
Correct Answer: 3
Question 5 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 clients pain. Which phase of the nursing process is this nurse implementing?
- Assessment
- Diagnosis
- Implementation
- Evaluation
Correct Answer: 3
Question 6 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 hour
- 12 hours
- 48 hours
- 24 hours
Correct Answer: 4
Question 7 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?
- Medical record from the childbirth
- Grandmother
- Parents 2 / 4
- Admitting physician
Correct Answer: 3
Question 8 A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client?
- In order to make sure all of your information is complete, I need to ask these questions.
- Youre right. Let me know if theres anything you need right now.
- Ill be done shortly, just give me a few more minutes.
- You shouldnt be upset. Were only doing our jobs.
Correct Answer: 2
Question 9 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?
- Examining
- Interviewing
- Listening
- Observing
Correct Answer: 4
Question 10 A nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for this particular nurse?
- A client with audible breathing
- Moaning of a client in pain
- Whirring of ventilators
- Co-orkers discussing their clients conditions
Correct Answer: 3
Question 11 3 / 4
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
Question 12 During an initial interview, the client says I dont understand why I have to have surgery; Im really not that sick or in pain right now. How should the nurse respond to the client?
- Its 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
Question 13 The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use?
- 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
Question 14 The nurse is assessing a client level of pain. Which open-ended question should the nurse use for this situation?
- Is your pain worse at night?
- / 4