NURA 1110 Final Exam Study Guide Questions with Complete Solutions A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing? - Correct Answer Time- lapse assessment is used Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? - Correct Answer Focus assessment Which traits of the nurse are most important for an assessment to be successful? - Correct Answer Trustworthy and confident Which statement is true regarding addressing a priority problem? - Correct Answer A priority problem requires a nursing intervention before another problem is addressed.A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records? - Correct Answer Impaired Physical Mobility related to pain When used in a nursing diagnosis, the descriptor "impaired" has which meaning? - Correct Answer Weakened or damaged The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action? - Correct Answer Notify the physician for additional orders.A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis? - Correct Answer The client states, "I am sure the doctors have misdiagnosed me." "Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis? - Correct Answer Actual nursing diagnosis 1 / 3
The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome? - Correct Answer The nurse has omitted the time frame.Which is an example of a nurse-initiated intervention? - Correct Answer Teaching a client how to splint an abdominal incision when coughing and deep breathing.The nurse is considering the needs of the postoperative client in his home setting. What is the nurse performing? - Correct Answer discharge planning A nurse is planning care for an adult client with severe cognitive impairments and a new diagnosis of lung cancer. What nursing action is most appropriate when establishing the priorities of care? - Correct Answer Include the client and his power of attorney in the discussion.What does etiology identify? - Correct Answer identifies factors causing undesirable response and preventing desired change.A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care? - Correct Answer Reassess the client to determine the effectiveness of the interventions.A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? - Correct Answer Discuss possible alternatives to a blood transfusion with the physician.Which is an independent (nurse-initiated) action? - Correct Answer Helping to allay a client's fears about surgery Which are activities the nurse typically performs during the implementation step of the nursing process? Select all that apply. - Correct Answer Collecting additional client data Modifying the client plan of care Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? - Correct Answer Does this task fall within the scope of a UAP? 2 / 3
Which authoritative statements guide current professional nursing practice? - Correct Answer American Nurses Association Standards of Nursing Practice The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example
of: - Correct Answer a cognitive outcome.
A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement? - Correct Answer Physical changes A nurse assures a client newly admitted to the clinical unit that the client will not be harmed by any errors and can expect to be safe in the facility. This assurance represents which expectation of the health care environment? - Correct Answer Safety The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? - Correct Answer Ensuring that the endotracheal tube is secure The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? - Correct Answer reporting The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? - Correct Answer subjectivity A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? - Correct Answer "Any information that can identify a person is considered a breach of client privacy." A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator? - Correct Answer Translators may need additional explanations of medical terms.Which actions should the nurse take before making an entry in a client's record? Select all that apply.
- Correct Answer Reviewing the agency's list of approved abbreviations
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