LPN To RN Transitions 3rd Edition By Lora Claywell – Test Bank

Chapter 11: Providing Patient-Centered Care Through the Nursing Process
Test Bank

MULTIPLE CHOICE

1. Which statement by the nurse illustrates how a nursing patient assessment differs from a medical patient assessment?
a. “The patient is able to stand for 30 seconds before walking 10 feet toward the bathroom without an assistive device.”
b. “The patient is fearful that he will not be discharged home after his hospitalization.”
c. “The patient stated he felt pain in his lower back after slipping on his icy driveway.”
d. “The patient experienced a persistent cough, and azithromycin was prescribed 6 weeks ago. Today, she presents with a recurrent cough, green sputum, and worsening shortness of breath.”

ANS: A
The patient’s being able to stand and walk is the correct answer. The nurse focuses on functional abilities and deficits in order to focus the plan of care and help identify the outcome priorities. These areas are not generally assessed by the physician. The patient’s feeling fearful of his disposition at discharge is incorrect because the nursing patient assessment does not focus on feelings and behavior. In addition to subjective data illustrated here by the patient’s stating the location of his pain, the nurse also uses objective data for the nursing patient assessment. The statement describing the patient’s medical history is not the focus of a nursing patient assessment.

DIF: Cognitive Level: Evaluation REF: Page 164
OBJ: Differentiate between the nursing patient assessment and the medical patient assessment.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care

2. The nurse is using Gordon’s 11 categories for data collection in performing a health assessment. Which of the following represents assessment of cognition?
a. How educated is the patient?
b. How does the patient describe his or her health?
c. Is the patient well nourished?
d. Has the patient had treatment for emotional problems?

ANS: A
Asking the patient’s educational level is an assessment of cognition. How the patient describes his or her health is an assessment of health perception and health management. Asking whether the patient is well nourished will assess metabolic pattern, and asking the patient about treatment for emotional problems will assess the patient’s pattern of coping and stress tolerance.

DIF: Cognitive Level: Application REF: Page 165
OBJ: Discuss the five realms that may affect a patient’s health status that should be addressed in order to complete a thorough nursing assessment. TOP: Nursing Process
MSC: NCLEX: Psychosocial Integrity

3. The nurse is charting on the patient who is status post surgery for an abdominal abscess and notes: “Pt’s temperature has not exceeded 37°C this shift.” This is an example of a(n):
a. intervention.
b. outcome.
c. plan.
d. diagnosis or analysis.

ANS: B
An outcome measures the effectiveness of the plan of care. An intervention, a plan, and a diagnosis or analysis are incorrect.

DIF: Cognitive Level: Analysis REF: Page 168
OBJ: Compare and contrast the nursing tasks in each phase of the nursing process.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care

4. Which outcome statement is a properly written goal?
a. “The patient will be free of pain.”
b. “The patient will verbalize the importance of lifestyle changes.”
c. “The patient will get up into the chair one time daily for 1 hour.”
d. “The patient will demonstrate breathing techniques by the end of shift.”

ANS: C
To be evaluated, an expected outcome must be specific and measurable, meaning that the outcomes can be consistently evaluated. “The patient will get up into the chair one time daily for 1 hour” is specific and measurable. The other outcome statements are vague and open to interpretation. First, being free from pain may mean absolutely no pain or a tolerable level of pain. Second, identifying which lifestyle changes are important to teach the patient may differ from nurse to nurse. Finally, there may be several breathing techniques to teach the patient.

DIF: Cognitive Level: Evaluation REF: Page 168
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care

5. The nurse is planning care for a patient with hypertension and obesity. Which of the following is a reasonable and measurable outcome for the nursing diagnosis of noncompliance with treatment regimen related to side effects of medications?
a. The patient will state two lifestyle modifications for weight management by (date certain).
b. The patient will be compliant with the treatment regimen by (date certain).
c. The patient will understand the disease process by (date certain).
d. The patient’s blood pressure will never increase.

ANS: A
The patient’s stating two lifestyle modifications for weight management is reasonable and measurable. The patient’s being compliant with the treatment regimen is vague. The patient’s understanding the disease process does not state how the effectiveness of teaching will be measured (e.g., by return demonstration or verbalization). The patient’s blood pressure not increasing is not reasonable.

DIF: Cognitive Level: Application REF: Page 168
OBJ: Formulate and apply reasonable and measurable outcomes to the practice setting.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care

6. A patient admitted with a diagnosis of Alzheimer’s disease is anxious and dehydrated, has reportedly not been eating, and has had a weight loss of 5 lb in 1 week. Which nursing diagnosis is a priority?
a. Fluid volume deficit related to fluid loss
b. Altered nutrition: Less than body requirements related to anorexia
c. Fluid volume excess related to reduced urine output
d. Risk for impaired skin integrity

ANS: A
Replacing fluids is the priority. Anorexia is common in the elderly and can be related to many conditions, including dementia. Fluid volume excess is not present. Risk for impaired skin integrity is not the priority.

DIF: Cognitive Level: Analysis REF: Page 167
OBJ: Formulate an actual, potential, and wellness nursing diagnosis.
TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care

7. An RN team leader has one LPN and one medical assistant assigned to the unit. Which patient would be most appropriate to assign to the LPN?
a. Right lower lobectomy, one day postoperatively, whose temperature went from 37.1°C to 38.3°C during the last shift
b. 72-year-old right hip replacement, 2 days postoperatively, complaining of leg and chest pain
c. 48-year-old female patient who had a laparoscopic appendectomy 8 hours ago: urine output 165 mL, Hgb 7 g/dL, and Hct 21%
d. Post cerebral vascular accident 1 week ago who had a Dobhoff feeding tube inserted and is now on continuous feedings at 45 mL/hr

ANS: D
Licensed practical nurses can implement actions specific to the patient care needs. Monitoring the stroke patient and maintaining the continuous feeding is an appropriate delegation. LPNs can also collect data, perform basic teaching, record data as well as interventions, and report to the RNs the progress the patient is making. The patient one-day post-op from the right lower lobectomy, the patient with the hip replacement, and the patient with the appendectomy are inappropriate to delegate to a LPN because each requires a focused assessment, advanced interventions, evaluation, and updating of the patients’ plans of care and outcome priorities.

DIF: Cognitive Level: Application REF: Page 171
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care

8. Which of these strategies should be a priority when the nurse is planning care for a patient with hypertension?
a. Obtain less expensive antihypertensive medications.
b. Assist with dietary changes as the first action.
c. Follow evidence-based guidelines for appropriate interventions.
d. Teach about the impact of exercise on hypertension.

ANS: C
Planning goals and desired outcomes occurs in the planning phase. The plan of care includes the process of identifying the interventions needed for the patient to regain a level of independence at or higher than the patient had before admission into the hospital.

DIF: Cognitive Level: Application REF: Page 169
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care

9. The nurse reviews assessment findings for assigned patients. Based on this information, which patient demands the nurse’s immediate attention? The patient with:
a. renal failure on dialysis whose WBC is 10,000 mm3 (normal)
b. abdominal aneurysm whose blood pressure is 170/90
c. atrial fibrillation whose lab results show and INR of 2.5 (normal)
d. endocarditis who has a loud heart murmur

ANS: B
Assessment contains both objective and subjective data. Among other things, the nurse interprets laboratory data to determine whom to see first. The hypertensive patient with an abdominal aneurysm presents the greatest emergency. The patient on dialysis, the patient with A-Fib, and the patient with endocarditis all have normal lab values and clinical findings and present no urgent need for attention.

DIF: Cognitive Level: Application REF: Page 163
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care

10. While the nurse is taking the health history, the patient states, “My father and grandfather both had heart attacks and were unable to be very active afterward.” This statement is related to the functional health pattern of:
a. activity-exercise.
b. cognitive-perceptual.
c. health perception–health management.
d. coping-stress tolerance.

ANS: C
The information in the patient’s statement relates to risk factors that may cause cardiovascular problems in the future. Identification of risk factors falls into the health perception–health management pattern. This pattern describes a patient’s perceived pattern of health and how health is managed.

DIF: Cognitive Level: Knowledge REF: Page 164
OBJ: Explain the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe, Effective Care Environment: Management of Care