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In the process of planning a patients care, the nurse has identified a nursing diagnosis of Ineffective Health Maintenance related to alcohol use. What must precede the determination of this nursing diagnosis?
- A. Establishment of a plan to address the underlying problem
- B. Assigning a positive value to each consequence of the diagnosis
- C. Collecting and analyzing data that corroborates the diagnosis
- D. Evaluating the patients chances of recovery
Correct Answer: C
Rationale: In the diagnostic phase of the nursing process, the patients nursing problems are defined through analysis of patient data. Establishing a plan comes after collecting and analyzing data; evaluating a plan is the last step of the nursing process and assigning a positive value to each consequence is not done.
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The nurse admits a patient to an oncology unit that is a site for a study on the efficacy of a new chemotherapeutic drug. The patient knows that placebos are going to be used for some participants in the study but does not know that he is receiving a placebo. When is it ethically acceptable to use placebos?
- A. Whenever the potential benefits of a study are applicable to the larger population
- B. When the patient is unaware of it and it is deemed unlikely that it would cause harm
- C. Whenever the placebo replaces an active drug
- D. When the patient knows placebos are being used and is involved in the decision-making process
Correct Answer: D
Rationale: Placebos may be used in experimental research in which a patient is involved in the decision-making process and is aware that placebos are being used in the treatment regimen. Placebos may not ethically be used solely when there is a potential benefit, when the patient is unaware, or when a placebo replaces an active drug.
The nurse caring for a patient who is two days post hip replacement notifies the physician that the patients incision is red around the edges, warm to the touch, and seeping a white liquid with a foul odor. What type of problem is the nurse dealing with?
- A. Collaborative problem
- B. Nursing problem
- C. Medical problem
- D. Administrative problem
Correct Answer: A
Rationale: In addition to nursing diagnoses and their related nursing interventions, nursing practice involves certain situations and interventions that do not fall within the definition of nursing diagnoses. These activities pertain to potential problems or complications that are medical in origin and require collaborative interventions with the physician and other members of the health care team. The other answers are incorrect because the signs and symptoms of infection are a medical complication that requires interventions by the nurse.
During report, a nurse finds that she has been assigned to care for a patient admitted with an opportunistic infection secondary to AIDS. The nurse informs the clinical nurse leader that she is refusing to care for him because he has AIDS. The nurse has an obligation to this patient under which legal premise?
- A. Good Samaritan Act
- B. Nursing Interventions Classification (NIC)
- C. Patient Self-Determination Act
- D. ANA Code of Ethics
Correct Answer: D
Rationale: The ethical obligation to care for all patients is clearly identified in the first statement of the ANA Code of Ethics for Nurses. The Good Samaritan Act relates to lay people helping others in need. The NIC is a standardized classification of nursing treatment that includes independent and collaborative interventions. The Patient Self-Determination Act encourages people to prepare advance directives in which they indicate their wishes concerning the degree of supportive care to be provided if they become incapacitated.
While developing the plan of care for a new patient on the unit, the nurse must identify expected outcomes that are appropriate for the new patient. What resource should the nurse prioritize for identifying these appropriate outcomes?
- A. Community Specific Outcomes Classification (CSO)
- B. Nursing-Sensitive Outcomes Classification (NOC)
- C. State Specific Nursing Outcomes Classification (SSNOC)
- D. Department of Health and Human Services Outcomes Classification (DHHSOC)
Correct Answer: B
Rationale: Resources for identifying appropriate expected outcomes include the NOC and standard outcome criteria established by health care agencies for people with specific health problems. The other options are incorrect because they do not exist.
A terminally ill patient you are caring for is complaining of pain. The physician has ordered a large dose of intravenous opioids by continuous infusion. You know that one of the adverse effects of this medicine is respiratory depression. When you assess your patients respiratory status, you find that the rate has decreased from 16 breaths per minute to 10 breaths per minute. What action should you take?
- A. Decrease the rate of IV infusion.
- B. Stimulate the patient in order to increase respiratory rate.
- C. Report the decreased respiratory rate to the physician.
- D. Allow the patient to rest comfortably.
Correct Answer: C
Rationale: End-of life issues that often involve ethical dilemmas include pain control, do not resuscitate orders, life-support measures, and administration of food and fluids. The risk of respiratory depression is not the intent of the action of pain control. Respiratory depression should not be used as an excuse to withhold pain medication for a terminally ill patient. The patients respiratory status should be carefully monitored and any changes should be reported to the physician.