Fundamental Of Nursing 9th Edition By Potter – Test Bank

Chapter 11
Question 1
Type: MCSA
When learning how to implement the nursing process into a plan of care for a client, the student nurse realizes that part of the purpose of the nursing process is to:
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 or organized care is not part of the nursing process, though 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:
Page Reference: 178
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 01 Describe the phases of the nursing process.
Question 2
Type: MCSA
The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process?
1. Assessment
2. Diagnosis
3. Implementation
4. 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 item..
Global Rationale: Page Reference: 180
Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 04 Identify the four major activities associated with the assessing phase.
Question 3
Type: MCSA
The nurse is taking information for the client’s database. The client is not very talkative; is pale, diaphoretic, and restless in the bed; and tells the nurse to just “leave me alone.” Which of the following is an example of subjective data regarding this client?
1. Restlessness
2. “Leave me alone”
3. Not talkative
4. Pale and diaphoretic
Correct Answer: 2
Rationale 1: Restlessness is observable so it is not an example of 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 an example of subjective data.
Rationale 4: Paleness with diaphoresis iare observable so it is not an example of subjective data.
Global Rationale: Page Reference: 183
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 05 Differentiate objective and subjective data and primary and secondary data.
Question 4
Type: MCSA
The nurse is collecting information from a client’s family. The client is confused and not able to contribute to the conversation. The spouse states, “This is not his normal behavior.” The nurse documents this as which of the following?
1. Inference
2. Subjective data
3. Objective data
4. 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 since it is an observation by someone familiar woth the client’s usual behavior.
Rationale 3: Information supplied by family members, significant others, or other health professionals is considered subjective if it is not based on fact. Since this information is factual, in that the spouse is able to provide the nurse with information about the client’s routine behavior and patterns, that is objective data.
Rationale 4: The information provided by the spouse is not subjective since it is an observation by someone familiar woth the client’s usual behavior.
Global Rationale: Page Reference: 183
Cognitive Level: Understanding
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:
Question 5
Type: MCSA
A nurse is providing a back rub to a client just 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. Assessment
2. Diagnosis
3. Implementation
4. 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: Page Reference: 181-182
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 02 Identify major characteristics of the nursing process.
Question 6
Type: MCSA
A nurse has just been informed that a new admission is coming to the unit. According to the 2005 JCAHO requirements, how long does the nurse have to complete a physical assessment and have a documented history and physical on the chart?
1. 1 hour
2. 12 hours
3. 48 hours
4. 24 hours
Correct Answer: 4
Rationale 1: While the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each client have an initial assessment consisting of a history and physical performed and documented within specific time period but not 1 hour.
Rationale 2: While the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each client have an initial assessment consisting of a history and physical performed and documented within specific time period but not 12 hours.
Rationale 3: While the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each client have an initial assessment consisting of a history and physical performed and documented within specific time period but not 48 hour.
Rationale 4: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 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: Page Reference: 180
Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10 Contrast various frameworks used for nursing assessment.
Question 7
Type: MCSA
An infant has been admitted to the pediatric unit. The parents are quite worried and upset, and the grandmother is also present. In this situation, what would be the best source of data?
1. Medical record from the child’s birth
2. Grandmother, since the parents are upset
3. Parents
4. Admitting physician
Correct Answer: 3
Rationale 1: The baby’s birth record able to provide necessary information, but not to the extent as the parents.
Rationale 2: While 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. Even though the parents are upset, they 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 extent as the parents.
Global Rationale: Page Reference: 180-181
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 06 Identify three methods of data collection, and give examples of how each is useful.
Question 8
Type: MCSA
A client was admitted just prior to the shift change. The admitting nurse reported most of the information to oncoming staff, but did not have all of the client’s past records. The second nurse is completing the assessment and database and continues to question the client about much of the same information as the previous nurse. The client says, “Why don’t you people talk to each other and quit asking the same things over and over?” The best response of the nurse is:
1. “In order to make sure all of your information is complete, I need to ask these questions.”
2. “You’re right. Let me know if there’s anything you need right now.”
3. “I’ll be done shortly, just give me a few more minutes.”
4. “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. response.
Rationale 3: This option does not address the client’s legitimate concern nor 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 any therapeutic response.
Global Rationale: Page Reference: 183-184
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 09 Describe important aspects of the interview setting.
Question 9
Type: MCSA
The nurse makes this entry in the client’s chart: “Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. However, is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse.” This is an example of which method of data collection?
1. Examining
2. Interviewing
3. Listening
4. 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: Page Reference: 186
Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 06 Identify three methods of data collection, and give examples of how each is useful.
Question 10
Type: MCSA
A nurse has worked in the trauma critical care area for several years. Which of the following noises may become indiscriminate for this particular nurse?
1. A client with audible breathing
2. Moaning of a client in pain
3. Whirring of ventilators
4. Co-workers 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 co-workers discuss other clients on the unit is helpful in case the nurse has to attend to any one of them.
Global Rationale: Page Reference: 188
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10 Contrast various frameworks used for nursing assessment.