Funds 1 Unit 1&2

The nurse recognizes that the stethoscope most correctly represents which possible link in the chain of infection?

• Source

• Mode of Transmission

• Portal of Entry

• Portal of Exit

Answer explanation

The stethoscope would be a means for the pathogen to travel from source to host. The source is the reservoir or host. The portal of exit is where the pathogen escapes from the reservoir of infection, and the portal of entry is where the microorganism enters the susceptible host.

A group of patients in a community center attend a nursing-led information session on the risks of contracting tuberculosis. After the presentation, several patients ask the nurse for additional web-based resources regarding the lung disease. Which type of nursing diagnosis would the nurse choose for the community care plan?

• Risk

• Problem-Focused

• Potential

• Health promotion

Answer explanation

Health promotion nursing diagnoses are clinical judgments concerning the motivation and desire of an individual, family, group, or community to increase well-being and to actualize human health potential. Health promotion nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. Although most nursing diagnoses are used for individual patients, nursing diagnosis taxonomy can be applied to families, groups of individuals, and communities. Problem-focused nursing diagnoses are clinical judgments about undesirable human responses to health conditions or life processes that occur in an individual, family, group, or community. Risk nursing diagnoses identify risk factors that are vulnerabilities of an individual, family, group, or community for developing negative human responses to health conditions or life processes. Potential is no longer a term used in identifying nursing diagnoses. Health promotion nursing diagnoses are clinical judgments concerning the motivation and desire of an individual, family, group, or community to increase well-being and to actualize human health potential.

What response would the nurse provide to correctly identify the most effective method to prevent hospital-acquired infections?

• Handwashing

• Antibiotic use

• Isolation protocols

• Use of Sterile Technique

The nurse is caring for a patient who is comatose. When preforming oral hygiene, which interval is most appropriate?

• Daily

• Every 4 hours

• Twice daily

• Every shift

The nurse correctly identifies which patient as having the highest risk for injury related to temperature of water when bathing?

• Patient with asthma

• Patient with attention deficit hyperactivity disorder

• Patient with diabetes

• Patient with a stroke

The nurse is preparing to give a patient a complete bed bath. What area of the body should be bathed first?

• Hands

• Face

• Eyes

• Arms

The nurse knows changes in which body system affect overall mobility increasing the propensity of falling?

• Neurologic

• Cardiopulmonary

• Musculoskeletal

• Hepatic

Answer explanation

Impairments in the musculoskeletal system can impact mobility through restrictions of range of motion and strength, increasing the chances of falling. Changes to the neurologic system can impair cognitive functioning, changes to the hepatic system can affect cognitive and physical status, and changes to the cardiopulmonary system can affect activity tolerance.

The nurse is writing the care plan for a patient admitted to the hospital for complications associated with muscular dystrophy. Which nursing diagnosis written on the care plan indicates a need for further instruction in constructing the diagnostic statement?

• Impaired airway clearance related to muscle weakness

• Constipation related to immobility as manifested patient passing hard, dry stool with difficulty

• Activity intolerance related to weakness as evidenced by verbal report of fatigue

• Impaired self-feeding related to fatigue as manifested by inability to open containers and bring food to the mouth

Answer explanation

Each type of nursing diagnostic statement contains sections or parts to comply with NANDA-I guidelines. Problem-focused nursing diagnostic statements are written with three parts: (1) a diagnosis label, (2) related factors, and (3) defining characteristics. Risk nursing diagnoses have two segments: (1) a diagnosis label and (2) risk factors preceded by the phrase as evidenced by. Health promotion nursing diagnoses also are written with only two sections: (1) the diagnosis label and (2) defining characteristics. The impaired airway clearance label is missing the defining characteristics.

The nurse is documenting data collected during a health assessment interview. Which statement by the nurse indicates subjective data?

• "My last bowel movement was 4 days ago.”

• Abdomen distended; firm and tender.

• Color pink. Skin warm and dry. No sign of discomfort.

• Dark colored; hard pellet-shaped stool.

The nurse is teaching a student nurse about restraint use in patients. Which statement by the student nurse indicates a learning need regarding restraints?

• “Having all four side rails up on the bed is considered a restraint.”

•   “Death has been associated with the use of restraints.”

• “The use of restraints has been shown to decrease fall-related injuries.”

•   “Medications administered to control behavior are considered a chemical restraint.”

Answer explanation

Restraints may be physical or chemical. A physical restraint is a mechanical or physical device, such as material or equipment attached or adjacent to the patient’s body, used to restrict movement. Examples of physical restraints are wrist or ankle restraints, a jacket or vest, and side rails. A medication that is administered to a patient to control behavior is a chemical restraint. The use of restraints has been associated with patient injury including death and does not prevent patient falls.