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Worksheetsprinciple of nursing aya punya
Total questions: 23
Worksheet time: 12mins
You are collecting data from a new admission patient who is diagnosed of uncontrolled hypertension. Which information about your patient is of least priority?
Respiratory
Neurological
Psychosocial
Cardiovascular
Planning is a category of nursing behaviour in which
the patient determines the care needed
the doctor determines the plan of care for the patient
the nurse determines the health care needed for the patient
patient-centered goals and expected outcomes are established
A nurse makes a clinical judgment that man to be vaccinated is more vulnerable to
developing fear than a woman in the same or a similar situation. Which type of nursing diagnosis it is referring to?
Risk
actual
possible
wellness
A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which of the following evaluative statement is written correctly?
"Outcome not met."
"1/21/20-Patient reports no change in diet."
"Outcome not met. Patient reports no change in diet or activity level."
"1/21/20-Outcome not met. Patient reports no change in diet or activity
level."
Mr. CA just come back to ward from an operation: Which of the following nursing
diagnoses are written correctly?
Catheterization R/T urinary retention
Pain and fever related to upcoming abdominal surgery
Pain reinted to tissue trauma secondary to hand surgery as evidence by pain
ranked 4/10
Impaired Tissue Integrity related to infrequent turning as evidence by 3 cm diameter ankle ulcer
Which of the following action that is appropriate once a nurse assesses a patient condition and identifies appropriale nursing diagnoses?
Determine a list of priorities
Begins Physical assessment
Develop a plan for nursing care
Review of the assessment that done by other nurses
According to Maslow's hierarchy of needs, which of the following nursing diagnosis falls on the highest priority?
Anxiety
Sleep deprivation
Disturbed body image
Decrease Cardiac Output
Which of the following is an appropriate patient-centered goal for a nursing diagnosis of acute pain?
Determine effect of pain intensity on patient function
Pain intensity reported as a 3 or less during hospital stay
Encourage patient to implement guided imagery when pain begins
Administer analgesic 30 minutes before physical therapy treatment
Nurse SS has received her patient assignment for the day-shift. After making the initial rounds and assessing the patients, which patient would nurse SS needs to develop a care plan first?
patient who is ambulatory
A patient scheduled for a surgery at 1300
A patient, who has a fever, is diaphoretic and restless
A client who just had an appendectomy and has just received pain
medication.
Nurse M documents that the patient has voided 475 mL. during the shift via an
indwelling urinary catheter. What type of data has the nurse documented?
Covert
Objective
Subjective
Continuous
You are interviewing a patient and is focusing on avoiding comments and questions
that will slow down communication. Which sentence demonstrates the appropriate communication techniques?
"Do you have any additional questions for me?
When did you first notice the rash on your leg?"
"Have you ever heard the saying 'no pain no gain?"
"Why do you feel that way about your cancer diagnosis?"
The nurse prioritizes the patient interventions to provide oxygen to the patient first with respiratory distress. Which of the model is the nurse applying?
Body Systems Model
Functional Health Patterns
Human Response Patterns
Hierarchy of Human Needs
A nurse is justified in independently identifying and documenting which diagnosis
related to impaired elimination?
Ulcerative Colitis
Bowel Incontinence
Small Bowel Obstruction
Irritable Bowel Syndrome
A patient is brought to the emergency room in respiratory arrest and immediately
intubated and placed on mechanical ventilation. What is the most appropriate nursing
diagnosis for this patient?
impaired gas exchange
Ineffective airway clearance
Ineffective breathing pattern
Impaired spontaneous ventilation
You are caring for Mr. KC who is newly admitted with acute abdominal pain. Which nursing diagnosis is the priority for this Mr. KC?
Impaired comfort
Activity intolerance
Disturbed body image
Disturbed sleep pattern
The nurse writes an expected outcome statement in measurable terms. Which of the following statement is correct?
Patient will be pain free
Patient will have less pain
Patient will report pain acuity less than 4 on a scale of 0-10
Patient will take pain medication every 4 hours around the clock
Which of the following statements pertaining to an assigned patient the nurse needs to validate?
The patient reported an infected toe
A weight of 83 kg is recorded in the chart
The patient's blood pressure is 124/70 mm Hg
The patient has a hard, raised, red lesion on his right hand.
Which of the following items of subjective data would be documented in the medical record by the nurse?
Patient's face is pale
Patient feels nauseated
Cervical lymph nodes are palpable
Nurse assistant reports patient refused lunch
Mr. CK reports nausea and constipation. Which of the following would be the
appropriate nursing action?
Notify the physician
Collect a stool sample
Complete an abdominal assessment
Administer an anti-nausea medication
You are developing a nursing diagnosis for Ms. YB who has cachexia and decreased
weight. Which of the following nursing diagnosis is appropriate?
Anorexia nervosa and bulimia
Weight loss related to abdominal discomfort
Imbalanced nutrition: less than body requirements
Lack of adequate nutrition related to decreased calories
A nurse is giving postoperative care to a patient after a knee operation. What is a
possible short-term goal for this patient?
To prevent repeat surgery in the patient
To maintain a health and active lifestyle
To ambulate the patient to a bedside chair
To help the patient return to activities of daily life
Mr. SM with HIV has been admitted to hospital. Which nursing diagnosis should be of the priority, keeping in mind of Mr. SM's condition?
Risk for infection
Risk for ineffective coping
Risk for activity intolerance
Risk for imbalanced nutrition
Mr. PM is failing to follow the plan of care that was collaboratively developed. After
investigation you found that the plan of care is not appropriate for him. What is your next step in correcting this problem?
Ask Mr. PM's family to assist him in following the plan of care
Make changes in the plan of care based upon assessment data
Discuss the desired outcomes with Mr. PM and the importance of outcomes
Provide information to the Mr. PM on the benefits of complying with the plan
of care
