1) A client arrives at the emergency room clinic complaining of abdominal pain and diarrhea. In the moment in which he measures the vital signs to the client, the nurse is implementing Which of the phases of the nursing process? (2pts) a) Diagnosis b) Planning c) Intervention d) Assessment.
2) In which of the following situations does a nurse demonstrate that the nursing process estimate phase has been implemented? When: Change the client to a more comfortable position. Work with the client to select the expected results of care. He asks the patient what amount of food was eaten at lunch. Determine that the client's pain has been alleviated with the medication.
3) A client reports "my chest hurts, and my left arm feels numb." The nurse interprets this data as, which of the following types of data and sources of information? Data: (2pts) Objectives of a secondary source. Objectives of a primary source. Subjective of a primary source. Subjective of a secondary source.
4) During the estimated phase, before touching the client's abdomen, the nurse must perform, which of the following interventions? (2pts) a) Listen to intestinal sounds. b) Put on clean gloves. c) Percussing the four abdominal quadrants. d) Raise the head of the client's bed.
5) Which of the following objective data obtained during the estimate should the nurse record in the medical record? (2pts) a) Complaints of numbness of the right hand. b) Loss of hair in the lower part of both legs. c) The detailed description of pain in a limb. d) Itching on the scalp, especially in the afternoons.
6) Which of the following physical examination techniques does the nurse use to estimate the presence of a murmur in the abdomen? (2pts) a) Palpation b) Inspection c) Percussion d) Auscultation.
7) Before interviewing the client to complete the health history, the nurse must perform first, which of the following interventions? Establish if there is a cover or medical plan. Ask the client to undress and put on a gown. Establish a therapeutic relationship with the client. Offer the patient a drink of their choice.
8) Which of the following techniques a nurse uses first to examine the abdomen of his client? Palpation Percussion Inspection Auscultation.
9) When completing the client's health history, the first action the nurse must take after the client describes their main complaint is: Refrain from taking note to appear focused on what the client says Paraphrase in the nurse's own words what the client's problem is. Document word by word what the client says about their problem. Ask the client to repeat the data to guarantee reliability.
10) A nurse was assigned to the care of a 25-year-old client who has just arrived at the emergency room referring to abdominal pain in the lower right quadrant of the abdomen, which radiates to the right leg and which he describes as severe and continuous. When the application of the nursing process begins, the nurse recognizes that which of the following steps to follow in the process is the first? Estimate the patient's complaints. Document the interventions. Determine the need for help from the client.
Perform nursing interventions.
11) A nurse was assigned to the care of a 14-year-old adolescent with a diagnostic of viral gastroenteritis. The client complains of severe abdominal pain with diarrhea and flatulence. When the nurse develops the care plan for this client, he recognizes that, in order of priority, what would be the first health need to work? The diarrheas. The gastroenteritis The flatulence. Abdominal pain.
12) A nurse assessing the condition of the abdominal wound of a client who recently had surgery for pancreatic cancer. While performing the client's estimate, the nurse records the following findings: The vital signs are stable, within the limits prior to surgery, the extremities are hot with good pulses, but the skin is dry. The client is drowsy when he is not sleeping; the client's pain is scored at 2 on a scale of 0-10. The client refuses to eat food and fluids by mouth because he experiences nausea and reports that he has not evacuated in the last 2 days. The wound dressing is dry with drains intact.
13) When the nurse examines the client's skin and finds injuries, which of the following objective data should this examiner assess carefully in each injury and write down the medical record? (2pts) Location, size, color, type of injury, grouping and distribution. Color, type of injury, date it appeared and level of pain. Location, level of pain, color, type of injury and date of appearance. Location, color, effects on the client's image and type of injury.
14) A nurse receives in the emergency room a client injured by a stray bullet that hits him in the chest. The visibly affected family cries and shouts that "please save the life of our family member". The nurse recognizes that which of the following methods to obtain objective data on this client's health condition is the most appropriate in this situation? The observation and physical exploration of the client. Observation of the behavior of family and friends. Interview the client directly about what happened. Consult with other health service providers.
15) A child is admitted with Dx Gastroenteritis doctor. It is observed with pale gums, lips and dry skin and generalized weakness. He has nausea and vomiting projectiles with two foul-smelling diarrhea and flatulence. When estimating the child's health condition, the nurse knows that he will offer care to, which of the following child's health needs? Stomach flu Nausea and vomiting. Dehydration Gastric ulcer.
16) A 54-year-old client arrives at the emergency room complaining of severe pain in the abdomen. When the nurse proceeds to evaluate the client's health condition, he / she recognizes that, which of the following is a physical examination technique should be used to assess the texture, temperature, size, consistency and location of the pain in the client's abdomen? Inspection Percussion Auscultation Palpation.
17) A nurse is assigned to the care of a client with a medical diagnosis of HIV / AIDS. The client begins to complain of sore throat and difficulty swallowing solid foods. The nurse observes that the patient has oral lesions in the form of white plaques but understands that he must perform a more detailed evaluation of the mouth and throat. The nurse recognizes that he needs which of the following instruments? (2pts) a) Pen light, tongue depressors and a stethoscope. b) Gloves, Pen light and a tongue depressor. c) Pen light, disposable towels and gloves. d) Stethoscope, gloves and disposable towels.
18) Which of the following is a vesicle-like skin lesion that is filled with pus, has a rounded, raised shape, and varies in size? a) Tumor b) Taint c) Ulcer d) Pustule.
19) Which of the following diagnoses can we consider a health need of a client that can be treated by the nursing professional? a)AIDS b) Ineffective respiratory pattern c) Congestive heart failure d) Mellitus diabetes.
20) Which of the following is considered the source of primary information to collect estimated, subjective and objective data, which are reliable and legitimate? The client The family Friends The doctor.
21) Which of the following is the concept with which we name the client's information that we use to arrive at the exact knowledge of something, in order to deduce the legitimate consequences of a fact? (2pts) a)Data b) Messages c) Communication d) Testimonials.
22) Physical examination methods require that the nursing professional have the ability to use the senses of: a) Vision, smell, hearing and touch b) Touch, taste, smell and vision c) Hearing, touch, smell and taste d) Smell, hearing, taste and vision.
23) A nurse was assigned to the care of an alcoholic client of 35 years, admitted with a medical diagnosis of pancreatic cancer metastasized to the liver and stomach. The client experiences abdominal pain, cries continuously, stays in a fetal position. The nurse observes how the client presses his abdomen and refers, "I have a lot of stomach pain, it is strong and it burns me". The nurse recognizes that, which of the following is a subjective datum that should be considered in the nursing note? (2pts) It remains in a fetal position. "I have a strong stomach pain and it burns me" He cries continuously. The abdomen is tightened.
24) A 2-year-old girl is admitted with a medical diagnosis of Viral Infection and Dehydration. The nurse observes the withdrawn child with generalized weakness, dry lips and pale gums. It presents vomiting and diarrhea. After examining the client, the nurse validates the inferences he made about the data obtained in the health estimate and recognizes that which of the following is the main cause for the dehydration of the client? (2pts) a) Viral infection. b) Vomiting and diarrhea. c) General weakness d) Gums, lips and skin pale and dry.
25 A 12-year-old boy arrives in the emergency room complaining of severe pain in his abdomen. The mother reports that she had 6 episodes of diarrhea in her house, and that she has not wanted to eat or drink liquids for 2 days. When measuring the vital signs, the temperature reflects fever of 39º C. In his estimate of the client's state, the nurse recognizes that, which of the following is an objective data? (2pts) a) Take 2 days without wanting to eat or drink liquids. b) Fever of 39º C c) Severe pain in the abdomen. d) 6 episodes of diarrhea.
26) An Alzheimer's client who is under nursing care suffers a sudden fall. The nurse finds him on the floor of the disoriented room, with a bruise on his forehead, presenting difficulty in breathing and with a headache. When making modifications to the client's care plan, the nurse recognizes that which of the following nursing diagnoses is of the highest priority when working with this new need for the client's health? (2pts) Falling risk Pain Ineffective breathing pattern Altered processes of thought.
27) When we elaborate a nursing diagnosis, we must consider that the label or denomination of NANDA is the equivalent to the formulation of: The cause or etiology of the need for health The medical diagnosis The need for health The characteristics of the need for health.
28) When we elaborate a nursing diagnosis, we must consider that the one related to or focal stimulus is the equivalent to the formulation of: (2pts) a) The need for health. b) The signs and symptoms of the need for health c) The characteristics that define the need for health. d) The cause or etiology of the need for health.
29) The nursing professional must diagnose and treat the client's health needs, which are real (current) and those at risk of experiencing him and his family. This professional recognizes that, the health needs in "Risk" are those that indicate us, which of the following? (2pts) Fears Fear Vulnerability Strengths.
30) Which of the following behaviors would indicate that the nurse was applying the estimate phase of the nursing process to provide nursing assistance to his client?(2pts) It generates the expected results of care. It proposes diagnoses about the health needs of the client. Check the results of the laboratory tests. Record the client's attendance to a radiological study.
31) Which of the following elements is best classified as a subjective data from a secondary information source? The client says that he feels intense pain in his legs when he climbs the stairs. The nurse palpates the lower extremities and finds that there is edema. The wife says that the client has a lot of pain. The nurse weighs the patient and verifies that a loss of 5kg in weight since the last visit.
32) A nurse wants to determine a client's feelings regarding a recent medical diagnosis. During the interview process, with which of the following questions are you most likely to get this information? What did the doctor tell you about your diagnosis? Could you tell me what was your husband's reaction to the diagnosis the doctor gave him? Are you worried about how the diagnosis will affect you in the future? How is your family responding to the news of this medical diagnosis?.
33) The use of a conceptual framework to collect and organize the estimated data on the health of the client-family guarantees, which of the following aspects? (2pts) a) Demonstration of profitable assistance b) Use of creativity and intuition in the beginning of the care plan. c) Checking the data with other members of the healthcare team. d) Collect all the necessary information to complete the assessment.
34) A nurse is preparing the nursing diagnoses of a client suffering from a seizure disorder. Which of the following elements is essential when we perform the analysis of the estimation data and the formulation of the diagnostic statement? Establish what the health needs and strengths of the client are. Estimate the cost of using different methods. Assess the client's health needs. Determine which interventions are most likely to succeed.
35) In the diagnostic statement: Excess fluid volume related to the reduction of venous return manifested by edema (swelling) of the lower extremities, which of the following is the cause or ethology of the client's need for health? (2pts) Unknown Edema Excess liquid volume. Reduction of venous return.
36) According to the PES format, which of the following statements contains the essential components of a nursing diagnosis? (2pts) Sleep deprivation secondary to fatigue and a noisy environment. Reduction of communication due to a stroke. Risk of caregiver stress related to the unpredictable course of the disease. Risk of falls related to the tendency to collapse when you have difficulty breathing manifested by short and flat breaths.
37) Which of the following is one of the main advantages of using the diagnostic statement in three parts using the PES format: problem-etiology-sign / symptom? Reduces the cost of medical-hospital care. Centers nursing assistance in the elements of health and welfare of the client. Standardize the organization of patient’s data. Improves communication between the nursing professional and the client.
38) Which assessment is most important for the nurse to make before advancing a client from liquid to solid food? (2pts) a) Bowel sounds b) Chewing ability c) Current appetite d) Food preferences.
39) The client is speaking of a symptom. What does the nurse say to better understand the symptom? “Point to where the symptom is” “Tell me what body part is affected by symptom” “Bring someone along who has seen the symptom” “Return when the symptom reoccurs”.
40) When examining a client who is complaining of left knee pain, which part of body should be examined? The left hip, knee and ankle. The left arm and leg. The abdomen on the left side. The left knee.
41) The nurse is interviewing a client about his health. When he asks him to explain what he means by a specific piece of information, what communication technique is being used? (2pts) a) Reflection b) Restarting c) Informing d) Clarification.
42) A nurse is taking a health history of a client. What statement does the nurse make that indicates she is using reflection. “I can understand why you are upset that you have been admitted to the hospital” “Have you considered changing medications for your diabetes?” “I’m listening” “Only one visitor at a time is allowed at this hospital”.
43) The main goal of the nursing process is to: (2pts) a) Diagnose conditions that nurses are licensed to treat. b) Organize and deliver nursing care. c) Formulate a care plan for the patient. d) Determine if nursing can affect the patient’s health.
44) A 25-year-old woman presents in the emergency department with acute abdominal pain in her right lower quadrant. This is the woman’s first time in a hospital; the nurse should first assess her: Circulation Abdomen Respiratory status Pain.
45) The Three phases of nurse-patient interview are: (2pts) Orientation, working, ongoing. Orientation, working, termination. Introduction, ongoing, termination. Introduction, working, termination.
46) Which is an open-ended questions? (2pts) How often have you taken pain medication? Do you think you may have eaten something bad? Tell me about your pain. Does it hurt when you urinated?.
47) After the review of systems is documented, the nurse’s next assessment step is to: Perform a physical examination. Make a nursing diagnosis. Look at the laboratory data. Medicate.
48) Patient’s assessment data are organized and analyzed by the nurse, and then the next step is for the nurse to develop: A nursing diagnosis Intuition Critical thinking Reflection.
49) The primary reason for diagnostic statement that do not depict the problems of the patient is: Over analyzing the data collected. Using the wrong type of diagnosis. Poor assessment. Clustering too many patterns.
50) In the order to prioritize nursing care, the nurse should start with the diagnosis that: (2pts) a) Affects safety b) Affects breathing c) Affects airway d) Affects circulation.
52) As the nurse in a primary care clinic, which cultural concern would you integrate into your psychological assessments of your clients? Concerns revolving around the lack of financial and health insurance resources to pay for psychological care Concerns related to the compliance with psychological treatment regimens because of the client’s lack of social support systems The concern related to the client’s cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders The concern related to the culturally based client apathy about nursing care and nursing assessments.
53) Which of the following steps is the final step that is used during the physical assessment of the abdomen? (2pts) Light palpation Deep palpation Percussion Inspection.
54) Which sound should you expect to hear when you percuss the liver during a complete physical assessment? Tympany Flatness Resonance Flatness Tympany Dullness Resonance.
55) A comprehensive health assessment includes: A complete medical history, a general survey and a focused physical assessment. A client interview, a significant other interview, a general survey and a complete physical assessment. A complete medical history, a general survey and a complete physical assessment. A client interview, a significant other interview, a general survey and a focused physical assessment.
56) Which statement about targeted assessments is accurate? Targeted assessments consist of a brief medical history and a complete assessment consists of a complete health history and a complete physical assessment. The need for a targeted assessment is based on the application of the nurse’s knowledge of developmental needs and developmental delays. The need for a targeted assessment is based on the application of the nurse’s knowledge of pathophysiology and the presenting symptoms. Targeted assessment is done on an annual basis for existing clients rather than a complete assessment that is done for new clients.
Goals and outcomes of patient care should be: (select all that apply) todas son correctas excepto NURSING BASED
Nursing based Patient centered Evidence based Measurable Realistic.
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