Nokea
A client is admitted to the hospital for control of diabetes mellitus. When does the nurse understand the nursing process begins?
- A. When the client enters the healthcare system
- B. Prior to the client being discharged
- C. After the nurse initiates the plan of care
- D. When the health care provider writes the first prescription for care
Correct Answer: A
Rationale: The nursing process begins when a client enters the healthcare system. Prior to being discharged, after the plan of care is initiated, and when the healthcare provider writes the first prescription for care all occur after the client is already in the healthcare system.
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Which of the following pieces of information is included in the client database?
- A. Nursing care
- B. Diagnostic studies
- C. Plan of care
- D. Collaborative problems
Correct Answer: B
Rationale: The client database includes all the information obtained from the medical and nursing history, physical examination, and diagnostic studies. The client database does not include nursing care, plan of care, or collaborative problems.
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.
Who should be involved in establishing specific and realistic outcomes so the client does not become frustrated in trying to achieve them?
- A. The client and family
- B. The physician
- C. Certified nursing assistant (CNA)
- D. Case management
Correct Answer: A
Rationale: The nurse includes the client and family in establishing outcomes. Outcomes are specific and realistic, so the client can attain them and not become frustrated, and measurable, so the nurse can reliably determine to what extent the client is meeting the goals. The physician, CNA, and case management do not play a role in the development of nursing outcomes.
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.
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.