A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip. Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
Question 2A patient has been admitted to the hospital for surgery and tells the nurse, I do not feel comfortable leaving my children with my parents. Which action should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patient's feelings about the child-care arrangements.
d. Call the patient's parents to determine whether adequate child care is being provided.
Question 3The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement, if made by the student nurse, indicates that teaching was successful?
a. The nursing process is a scientific-based method of diagnosing the patient's health care problems.
b. The nursing process is a problem-solving tool used to identify and treat patients' health care needs.
c. The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans.
d. The nursing process is used primarily to explain nursing interventions to other health care professionals.
Question 4The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which statement, if made by the nurse, would be the most accurate?
a. Inferences from clinical research studies are used as a guide.
b. Patient care is based on clinical judgment, experience, and traditions.
c. Data are evaluated to show that the patient outcomes are consistently met.
d. Recommendations are based on research, clinical expertise, and patient preferences.
Question 5The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patient's input. The patient states, How is this different from what the doctor does?
Which response would be most appropriate for the nurse to make?
a. The role of the nurse is to administer medications and other treatments prescribed by your doctor.
b. The nurse's job is to help the doctor by collecting information and communicating any problems that occur.
c. Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a longer time than the doctor.
d. In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.
Question 6The nurse suspects that patient who received intramuscular penicillin for treatment of secondary syphilis is developing the Jarisch-Herxheimer reaction. What information did the nurse use to make this clinical determination?
Select all that apply.
1. new onset of fever
2. heart rate 112 beats per minute
3. sudden severe abdominal cramping
4. complaints of musculoskeletal pain
5. administration of medication 16 hours ago
Question 7While planning care for a patient with pelvic inflammatory disease, the nurse identifies the goal of recovering without long-term effects. Which interventions should the nurse select to help achieve this patient's goal?
Select all that apply.
1. Instruct on perineal care.
2. Ensure thorough hand hygiene.
3. Disinfect bedpan and toilet seat.
4. Administer antibiotic therapy as prescribed.
5. Monitor for adverse effects of antibiotic therapy.
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