Nokea
The nurse has just taken report on a newly admitted patient who is a 15 year-old girl who is a recent immigrant to the United States. When planning interventions for this patient, the nurse knows the interventions must be which of the following?
- A. Appropriate to the nurses preferences
- B. Appropriate to the patients age
- C. Ethical
- D. Appropriate to the patients culture
- E. Applicable to others with the same diagnosis
Correct Answer: B,C,D
Rationale: Planned interventions should be ethical and appropriate to the patients culture, age, and gender. Planned interventions do not have to be in alignment with the nurses preferences nor do they have to be shared by everyone with the same diagnosis.
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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.
A medical nurse is caring for a patient who is palliative following metastasis. The nurse is aware of the need to uphold the ethical principle of beneficence. How can the nurse best exemplify this principle in the care of this patient?
- A. The nurse tactfully regulates the number and timing of visitors as per the patients wishes.
- B. The nurse stays with the patient during his or her death.
- C. The nurse ensures that all members of the care team are aware of the patients DNR order.
- D. The nurse liaises with members of the care team to ensure continuity of care.
Correct Answer: B
Rationale: Beneficence is the duty to do good and the active promotion of benevolent acts. Enacting the patients wishes around visitors is an example of this. Each of the other nursing actions is consistent with ethical practice, but none directly exemplifies the principle of beneficence.
During discussion with the patient and the patients husband, you discover that the patient has a living will. How does the presence of a living will influence the patients care?
- A. The patient is legally unable to refuse basic life support.
- B. The physician can override the patients desires for treatment if desires are not evidence-based.
- C. The patient may nullify the living will during her hospitalization if she chooses to do so.
- D. Power-of-attorney may change while the patient is hospitalized.
Correct Answer: C
Rationale: Because living wills are often written when the person is in good health, it is not unusual for the patient to nullify the living will during illness. A living will does not make a patient legally unable to refuse basic life support. The physician may disagree with the patients wishes, but he or she is ethically bound to carry out those wishes. A power-of-attorney is not synonymous with a living will.
A nurse is admitting a new patient to the medical unit. During the initial nursing assessment, the nurse has asked many supplementary open-ended questions while gathering information about the new patient. What is the nurse achieving through this approach?
- A. Interpreting what the patient has said
- B. Evaluating what the patient has said
- C. Assessing what the patient has said
- D. Validating what the patient has said
Correct Answer: D
Rationale: Critical thinkers validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence. The nurse is not interpreting, evaluating, or assessing the information the patient has given.
A recent nursing graduate is aware of the differences between nursing actions that are independent and nursing actions that are interdependent. A nurse performs an interdependent nursing intervention when performing which of the following actions?
- A. Auscultating a patients apical heart rate during an admission assessment
- B. Providing mouth care to a patient who is unconscious following a cerebrovascular accident
- C. Administering an IV bolus of normal saline to a patient with hypotension
- D. Providing discharge teaching to a postsurgical patient about the rationale for a course of oral antibiotics
Correct Answer: C
Rationale: Although many nursing actions are independent, others are interdependent, such as carrying out prescribed treatments, administering medications and therapies, and collaborating with other health care team members to accomplish specific, expected outcomes and to monitor and manage potential complications. Irrigating a wound, administering pain medication, and administering IV fluids are interdependent nursing actions and require a physicians order. An independent nursing action occurs when the nurse assesses a patients heart rate, provides discharge education, or provides mouth care.