Nursing Chapter 14 If the nursing diagnosis is accurate, as it is in this case

Question 18

Type: MCSA

A teenage client has been having problems with peer support, school performance, and parental expectations, all

of which contributed to an eating disorder. After gathering this assessment data, the nurse formulates the

diagnosis Activity Intolerance related to weakness. What should the nurse realize after evaluating this diagnosis?

1. The data collected would support the diagnosis.

2. The diagnosis is directly related to the data presented.

3. The nursing diagnosis is not relevant to the data.

4. The data are not sufficient enough to support this diagnosis.

Question 19

Type: MCSA

A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of

Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this

client is not to sustain any injuries for the next month; however, the client has fallen several times. In this situation,

what should the nurse do?

1. Review the data and make sure that the diagnosis is relevant.

2. Investigate whether the best nursing interventions were selected.

3. Modify the whole nursing plan.

4. Discard the nursing plan and start over from the assessment phase.

Question 20

Type: MCSA

The nurse manager has been appointed to implement a quality assurance program at the hospital. Which

components should the manager prepare to evaluate for this program?

1. Methods

2. Structure

3. Finances

4. Process

5. Outcome

Question 21

Type: MCSA

A care area has been short staffed for the past month with a heavy client load and high acuity. The nurses have

been working extra as well as double shifts and often do not have time to make sure that properly working

equipment is cleaned, returned, and stored in the appropriate areas. At what level should this care area be

evaluated?

1. Management

2. Structure

3. Process

4. Outcome

Question 22

Type: MCSA

A nursing unit has had a large number of negative client responses about various aspects of their care in the

previous quarter. When evaluating this care area, on which care component should the quality assurance officer

focus?

1. Competency

2. Structure

3. Process

4. Outcome

Question 23

Type: MCSA

A nursing unit’s records of client care have been reviewed for accuracy in documentation. Which type of review is

being completed on these records?

1. Nursing audit

2. Peer review

3. Individual audit

4. Concurrent audit

Question 24

Type: MCSA

The nurse reviews clients’ records and the care they received while in the hospital for an insurance company. Part

of the job description requires the nurse to make sure that the client and insurance company were billed for

services and treatment/therapies rendered and that there were no errors in billing. Which type of audit is the nurse

completing?

1. Concurrent

2. Peer review

3. Nursing audit

4. Retrospective

Question 25

Type: MCSA

The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task is completed

and documented correctly; however, one of the clients had a blood pressure reading of 180/110. The nurse learns

this information at the end of the shift. Which responsibility of delegation did the nurse fail to carry out?

1. Delegating to the appropriate staff

2. Delegating the appropriate task

3. Selecting the appropriate client

4. Appropriately supervising care

Question 26

Type: MCMA

The nurse is implementing care and treatments for assigned clients. What actions should the nurse prepare to

complete during this phase of the nursing process?

Standard Text: Select all that apply.

1. Evaluating the outcome of the interventions

2. Reassessing the client

3. Documenting the history and physical

4. Supervising delegated care

5. Implementing the nursing intervention

Question 27

Type: MCMA

After implementing interventions and reassessing the client’s response, the nurse completes the process by

evaluating. What attributes of evaluation should the nurse include when completing this step of the nursing

process?

Standard Text: Select all that apply.

1. Purposeful activity

2. Nursing accountability

3. Continuous

4. Judgments

5. Opinion

Question 28

Type: MCMA

The nurse is preparing to evaluate care provided to a client. What behaviors should the nurse demonstrate that

show an understanding of the relationship of evaluation to the other phases of the nursing process?

Standard Text: Select all that apply.

1. Effectively assessing the client’s needs

2. Selecting the appropriate nursing diagnosis related to the client’s needs

3. Collecting client-focused data with a specific need in mind

4. Evaluating by using assessment data to determine effective achievement of goals and outcomes

5. Basing evaluation on assessment data collected during the admission phase

Question 29

Type: MCMA

The nurse notes that assessment data indicate a change in a client’s condition. What should the nurse ask before

changing this client’s plan of care?

Standard Text: Select all that apply.

1. How difficult will it be to change the care plan?

2. Are the new data complete?

3. Are the new data accurate?

4. Do the new data require a change in the care plan?

5. Will the primary medical provider agree with the need to alter the care plan?

New Questions:

Question 30

Type: MCMA

The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of evaluation

were completed by the nurse appropriately?

Standard Text: Select all that apply.

1. Client problems updated

2. Data linked to NOC indicators

3. Data compared to desired outcomes

4. Interventions changed on the care plan

5. Physician notified of changes in the care plan

Question 31

Type: MCMA

A client recovering from total knee replacement surgery falls out of bed on the night shift and dies. Which quality

improvement actions should the nurse manager expect to complete for this client occurrence?

Standard Text: Select all that apply.

1. A root cause analysis

2. Paperwork about a sentinel event

3. Analysis of the nurse assigned to the client

4. Number of times the client was observed on the night shift

5. Number of hours since the client last received pain medication