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According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?
- A. Ineffective airway clearance
- B. Ineffective coping
- C. Impaired urinary elimination
- D. Risk for body image disturbance
Correct Answer: D
Rationale: The correct answer is D: Risk for body image disturbance. In Maslow's hierarchy, physiological needs like airway clearance take precedence over emotional or self-esteem needs like body image disturbance. Priority is given to addressing life-threatening issues first. Impaired urinary elimination could be related to the client's heart failure and should be addressed to prevent complications. Coping mechanisms are important for emotional well-being but are not as critical as physiological needs in this scenario.
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A nurse is updating the care plan of a client whose condition has improved. What is the most appropriate step to take?
- A. Remove resolved nursing diagnoses from the care plan.
- B. Continue with the existing care plan until discharge.
- C. Focus only on interventions for unresolved issues.
- D. Delegate the task to another nurse or staff member.
Correct Answer: A
Rationale: The correct answer is A because when a client's condition improves, resolved nursing diagnoses should be removed from the care plan to reflect the current status accurately. This ensures the care plan remains relevant and effective. Continuing with the existing plan (choice B) may lead to unnecessary interventions. Focusing only on unresolved issues (choice C) overlooks the importance of updating the care plan comprehensively. Delegating the task to another nurse or staff member (choice D) is not appropriate as the nurse updating the care plan should have a thorough understanding of the client's progress and needs.
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully. Choice B may overwhelm the patient, Choice C disrupts the communication process, and Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.
A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)
- A. Includes seven domains for level 1
- B. Uses an easy 3-point Likert scale
- C. Adds objectivity to judging a patient’s progress
- D. Allows choice in which interventions to choose
Correct Answer: C
Rationale: The correct answer is C because Nursing Outcomes Classification adds objectivity to judging a patient's progress by providing standardized criteria for assessing outcomes. This helps in evaluating the effectiveness of interventions and tracking improvements accurately. Other choices are incorrect: A is wrong because Nursing Outcomes Classification includes 7 domains but not necessarily for level 1; B is incorrect as it uses a 5-point Likert scale, not a 3-point scale; and D is inaccurate because Nursing Outcomes Classification guides the selection of interventions based on the identified outcomes, not allowing complete freedom in choosing interventions.
A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.
- A. Where is the pain located?
- B. What causes the pain?
- C. Does it come and go?
- D. What does the pain feel like?
Correct Answer: A
Rationale: The correct answer is A: Where is the pain located? This question corresponds to the "P" in PQRST, which stands for Provocation/Palliation. By asking where the pain is located, the nurse is gathering information about what triggers or relieves the pain, aiding in the assessment of the chest pain. The other choices are incorrect because:
B: What causes the pain? - This question corresponds to the "Q" in PQRST, which stands for Quality. It focuses on understanding the characteristics of the pain, not the cause.
C: Does it come and go? - This question corresponds to the "R" in PQRST, which stands for Radiation. It pertains to whether the pain spreads to other areas, not if it comes and goes.
D: What does the pain feel like? - This question corresponds to the "S" in PQRST, which stands for Severity. It relates to the intensity of the pain, not its location.
The best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:
- A. Extremities
- B. Head
- C. Eyeball
- D. Chest and nostrils A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET L
Correct Answer: D
Rationale: The correct answer is D, "Chest and nostrils." This is because observing the movement of the chest and nostrils is the most reliable way to determine if a patient is breathing. The chest rises and falls with each breath, and the nostrils may flare or move as air is inhaled and exhaled. Monitoring these areas provides a direct indication of respiratory effort. Choices A, B, and C are incorrect because they do not directly reflect the act of breathing. Extremities, head, and eyeball movements are not reliable indicators of breathing function.