Fundamental Nursing Skills and Concept 10th Edition Timby -Test Bank

2.

A client with HIV has been admitted to a health care facility. Which of the following nursing diagnoses should be of the highest priority, keeping in mind the client’s condition?

A)

Risk for activity intolerance

B)

Risk for ineffective coping

C)

Risk for infection

D)

Risk for imbalanced nutrition

Ans:

C

Feedback:

Clients with HIV have decreased immunity and are prone to infections. Infection in a client with HIV is life-threatening, because it makes the client vulnerable to other infections, and also impairs his or her already weakened immune functions. Clients with HIV may not have problems with other activities and food. They may often feel depressed, but this is not the highest priority.

3.

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data?

A)

Blood pressure

B)

Nausea

C)

Heart rate

D)

Respiratory rate

Ans:

B

Feedback:

Subjective data are those that the client can feel and describe. Nausea is subjective data, as it can only be described and not measured. Blood pressure, heart rate, and respiratory rate are measurable factors and are therefore objective data.

4.

A client who has to undergo a thyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?

A)

Risk for impaired physical mobility due to surgery

B)

Ineffective denial related to poor coping mechanisms

C)

Disturbed body image related to the incision scar

D)

Risk of injury related to surgical outcomes

Ans:

C

Feedback:

The client is concerned about the surgery scar on his neck, which would disturb his body image; therefore, the appropriate diagnosis should be disturbed body image related to the incision scar. Risk for impaired physical mobility may be present after surgery, but is not related to the concerns expressed by the client. Likewise, ineffective denial related to poor coping mechanisms and injury related to surgical outcomes are also not related to the client’s concern.

5.

A nurse is giving postoperative care to a client after knee arthroplasty. Which of the following is a possible short-term goal for this client?

A)

To ambulate the client to a bedside chair

B)

To help the client return to activities of daily life

C)

To maintain a healthy and active lifestyle

D)

To prevent repeat surgery in the client

Ans:

A

Feedback:

The short-term goal in this case is to help the client ambulate to the bedside chair. The other goals, such as helping the client return to activities of daily life, to maintain a healthy and active lifestyle, and to prevent repeat surgery in the client are long-term goals and may take weeks or months to achieve. On the other hand, short-term goals can be achieved in a day or a week.

6.

A nurse who is caring for a client admitted to the nursing unit with acute abdominal pain formulates the care plan for the client. Which of the following nursing diagnoses is the highest priority for this client?

A)

Impaired comfort

B)

Disturbed body image

C)

Disturbed sleep pattern

D)

Activity intolerance

Ans:

A

Feedback:

Acute pain in the abdomen disturbs all the systems of the body. Relieving the pain should be the nurse’s first priority. According to Maslow, physiologic needs are the highest priority. The client may have disturbed body image, disturbed sleep patterns, or activity intolerance, but all these are secondary to pain.

7.

The nurse is performing an assessment of a client diagnosed with excess fluid volume due to renal failure. Which of the following assessment data is the nurse likely to find?

A)

Hypotension

B)

Feeble pulse

C)

Crackles

D)

Drowsiness

Ans:

C

Feedback:

Crackles are the most important sign found in excess fluid volume. The client has the nursing diagnosis of excess fluid volume. The signs of increased fluid volume are adventitious lung sounds, a bounding pulse, and high blood pressure; therefore, a diagnosis of hypotension or feeble pulse would be incorrect. Consciousness may become impaired at later stages when the fluid shift starts. The adventitious lung sounds indicate excess fluid volume.

8.

A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. What nursing diagnosis is the priority in this client’s care?

A)

Impaired gas exchange related to the disease condition

B)

Impaired verbal communication related to the breathing problem

C)

Inability to speak due to ineffective airway clearance

D)

Impaired physical mobility related to shortness of breath

Ans:

A

Feedback:

The client is most likely experiencing impaired gas exchange as a result of the pathophysiology of asthma. This is a priority over mobility and communication issues, though each may be valid. Inability to speak due to ineffective airway clearance is not a proper nursing diagnosis.

9.

A nurse is caring for a client with Parkinson disease. Which of the following nursing diagnoses identified by the nurse should be of the highest priority?

A)

Impaired physical mobility

B)

Risk for memory loss

C)

Ineffective role performance

D)

Risk for injury

Ans:

D

Feedback:

Clients with Parkinson disease are at higher risk of injury due to their physical limitations and cognitive deficiencies. Therefore, it becomes important for the nurse to ensure that the environment is safe. The client may also have impaired physical mobility, risk for memory loss, and ineffective role performance, but the highest priority is to prevent injury and ensure the client’s safety.

10.

A nurse is caring for a client with cancer who is experiencing pain. Which of the following would be the most appropriate assessment of the client’s pain?

A)

Pain relief after nursing intervention

B)

Verbal and nonverbal cues of client

C)

The nurse’s impression of the client’s pain

D)

The client’s pain based on a pain rating

Ans:

D

Feedback:

The client’s assessment of pain, based on a pain rating, is the most appropriate assessment data. The pain is rated on a 1 to 10 scale and nursing actions are then implemented to reduce the pain. The nurse’s impression of pain and nonverbal clues are subjective data. Pain relief after nursing intervention is appropriate, but is a part of evaluation.