Nokea
A client has a nursing diagnosis of altered skin integrity related to prescribed bed rest and decreased mobility of the lower extremities as evidenced by a reddened area on heels and fluid-filled blister on sacrum. Which part of this nursing diagnosis is considered the cause?
- A. Altered skin integrity
- B. Fluid filled blister on sacrum
- C. Prescribed bed rest
- D. Reddened area on heels
Correct Answer: C
Rationale: The cause portion of the nursing diagnosis includes the factors contributing to the problem; in this case, they are 'prescribed bed rest and decreased mobility of the lower extremities.' Impaired skin integrity is the stated problem, and the reddened area on the heels and the fluid filled blister are the defining characteristics that describe the problem.
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An RN has developed a plan of care for a client and shares the plan with the LPN. Which intervention(s) can the LPN perform in the implementation phase for this client? Select all that apply.
- A. Provide basic therapeutic and preventive nursing measures.
- B. Provide client and family teaching.
- C. Exchange information with prescribing provider.
- D. Make referrals for ancillary services.
- E. Document care that is provided.
Correct Answer: A,B,E
Rationale: The role of the LPN in the implementation phase is to provide basic therapeutic and preventive nursing measures, provide client education, and record information. Exchanging information with the prescribing provider and making referrals are within the scope of practice of an RN.
Which of the following is the highest level of human need according to Maslow (1968)?
- A. Physiologic
- B. Love and belonging
- C. Esteem and self-esteem
- D. Self-actualization
Correct Answer: D
Rationale: The highest level need is self-actualization. The first level of need is physiological needs. Love and belonging are third-level needs. Esteem and self-esteem are fourth-level needs.
The RN develops an outcome standard of 'client will ambulate with an assistive device 60 feet with assistance twice a day' for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: Planning establishes the outcomes and actions that will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.
A client being cared for by the healthcare team has a large open abdominal wound after having a surgical procedure. The wound had to be reopened due to the development of infection and is left to heal with packing and dressing changes twice daily. What would be an appropriate measurable short-term outcome for this client?
- A. The wound will heal before the client is discharged.
- B. The client will be responsible for changing the dressing twice a day.
- C. The client will have no fever and no purulent discharge in 3 days.
- D. Dressing changes will be done twice a day using aseptic technique.
Correct Answer: C
Rationale: The client having no fever or purulent discharge in 3 days is a realistic measurable goal. The wound is large and will not heal within the time frame of discharge. It is unrealistic to have an outcome that the client will be able to change a dressing after a surgical procedure. Dressing changes twice a day is a nursing intervention.
Which of the following is a true statement about critical thinking according to Alfaro-LeFevre (2010)?
- A. It makes judgments based on conjecture.
- B. It is based on the medical model.
- C. It considers only the client's needs.
- D. It is guided by professional standards and codes of ethics.
Correct Answer: D
Rationale: Critical thinking is guided by professional standards and codes of ethics. It is based on principles of the nursing process and scientific methods. Critical thinking makes judgments based on evidence rather than conjecture. It considers client, family, and community needs.