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fUNDA rationale 2007 edited

fUNDA rationale 2007 edited

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Published by Quia Benjch Uayan

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Published by: Quia Benjch Uayan on Mar 08, 2011
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NAME ______________________ DATE _________ SCORE ______INSTRUCTION: Select the best answer for each of the followingquestions. Read the questions well. NO ERASURES.
1.A nurse is formulating a plan of care for a client receiving enteralfeedings. Which nursing diagnosis is of highest priority for this client?a. altered nutrition, less than body requirementsb. high risk for aspirationc. high risk for fluid volume deficitd. diarrhea
Answer: BRationale
: Any condition in which gastrointestinal motility is slowed oresophageal reflux is possible places a client at risk for aspiration.Options 1 and 4 may be appropriate nursing diagnoses but are not of highest priority. Option 3 is not likely to occur in this client.(Source: Mary Ann Hogan, Prentice Hall REVIEWS AND RATIONALESp204)2. A nurse recognizes that which of the following interventions isunlikely to facilitate effective communication between a dying clientand his or her family?a. The nurse encourages the client and family to identify anddiscuss the feelings openlyb. The nurse makes decisions for the client and family to relievethem of unnecessary demandsc. The nurse assists the client and family in carrying out spirituallymeaningful practicesd. The nurse maintains a calm attitude and one of acceptance whenthe family or client expresses anger
Answer: BRationale
: Maintaining effective and open communication amongfamily members affected by death and grief is of the greatestimportance. Option A describes encouraging discussion of feelingsand is likely to enhance communications. Option C is also aneffective intervention, because spiritual practices give meaning tolife and have an impact on how people react to crisis. Option D isalso an effective technique, as the client and family need to knowthat someone will be there who is supportive and nonjudgmental.Option B describes the nurse removing autonomy and decision-making from the client and family, who are already experiencingfeelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention, which can further impaircommunication. (Source: Kozier FUNDAMENTALS OF NURSING 7
Edp 1041)3. A client brought to the emergency department is dead on arrival(DOA). A family member of the client tells the physician that the clienthad a terminal cancer. The emergency department physicianexamines the client and asks a nurse to contact the medical examinerregarding an autopsy. The family of the client tells the nurse that they
do not want an autopsy performed. Which of the following responsesto the family is most appropriate?a. “it is required by federal law. Why don’t we talk about it, andwhy don’t you tell me why you don’t want the autopsy done?b. “the decision is made by the medical examiner.”c. “I will contact the medical examiner regarding your request.”d. “An autopsy is mandatory for any client who is DOA.”
Answer: CRationale:
An autopsy is required by state law in certaincircumstances, including the sudden death of a client and a deaththat occurs under suspicious circumstances. A client may haveprovided oral or written instructions regarding an autopsy followingdeath. If an autopsy is not required by law, these oral or writtenrequests will be granted. If no oral or written instructions wereprovided, state law determines who has the authority to consent foran autopsy. Most often, the decision rests with the surviving relativeor next of kin. (Source: Kozier FUNDAMENTALS OF NURSING 7
Ed p1044)4. A nurse is developing a postoperative plan of care for a 40-yearmale Filipino client scheduled for an appendectomy. The nurse mostappropriately includes in the plan of care to:
inform the client that he will need to ask for painmedication when needed
offer pain medication when nonverbal signs of discomfortare identified
offer pain medication on a regular basis as prescribed
allow the client to maintain control and request painmedication on his own
Answer: CRationale:
Filipinos view pain as part of living an honorable life.The client may appear stoic and be tolerant of a high degree of pain. Health care providers need to offer, and in fact encourage painrelief interventions for the Filipino client who does not complain of pain despite physiological indicators. Option c is the mostappropriate intervention to include in the plan of care. (Source:Kozier FUNDAMENTALS OF NURSING 7
Ed p 1140)5. A nurse has developed a plan of care for a client who is in tractionand documents a nursing diagnosis of Self-Care Deficit. The nurseevaluates the plan of care and determines that which of the followingobservations indicates a successful outcome?a. the client allows the nurse to complete the care on a dailybasisb. the client allows the family to assist in the carec. the client refuses cared. the client assists in self-care as much as possible,
Answer: DRationale:
A successful outcome for the nursing diagnosis of Self-Care-Deficit is for the client to do as much of the self-care aspossible. The nurse should promote independence in the client andallow the client to perform as much self-care as is optimalconsidering the clients condition. The nurse would determine thatthe outcome is unsuccessful if the client refused care or allowsothers to do the care. (Source: Kozier FUNDAMENTALS OF NURSING7
Ed p 39)
6. A registered nurse (RN) is planning assignments for the clients on anursing unit. The RN needs to assign four clients and has a registerednurse and two nursing assistants on a nursing team. Which of thefollowing clients would the nurse most appropriately assign to thenursing assistants?a. A client who requires a 24-hour urine collectionb. An elderly client requiring assistance with a bed bath andfrequent ambulationc. A client on a mechanical ventilator who requires frequentassessment and suctioningd. A client with an abdominal wound requiring wound irrigationsand dressing changes every 3 hours
Answer: BRationale:
When delegating nursing assignments, the nurseneeds to consider the skills and educational level of the nursingstaff. Collecting a 24-hour urine and frequent ambulation canmost appropriately be provided by the nursing assistantconsidering the clients identified in each of the options. Theclient on the mechanical ventilator requiring frequentassessment and suctioning should most appropriately be caredfor by the registered nurse.(Source: Kozier FUNDAMENTALS OF NURSING 7
Ed p 476, 477)7. Nursing has been focused on health and caring. Traditionally,nursing was concerned with:a. attending to the poorb. keeping people healthy and wellc. caring for the sick and the infirmedd. working with the “dregs” of society
Answer: CRationale:
In the past, the traditional nursing role was one of humanistic caring or both men and women comforted and caredfor the sick and those unable to care for themselves; wasnurturing, comforting and supporting. Nurses are mentionedoccasionally in the Old Testament as women who provided carefor the infants and children, for the sick and dying. (source: FNPby Kozier, 5
ed., p. 4)A – anyone who was sick is being provided with care whetherpoor or richB – is the concern in modern timesD – is unrelated8. Nursing has evolved from a subservient role to one that is:a. people-oriented c. coordinate roleb. handmaid of doctor d. self-regulatory
Answer: DRationale:
Means that modern nurse can act independentlywithout being subjected to another person’s will /want. The nurseis constantly assuming responsibilities in patient care and arefulfilling expanded nursing roles, for example, those of the nursegeneralist, the nurse clinician and advanced nurse practioner.(Source: FNP by Kozier, 5
ed., p. 21)A- unrelated to the question but nowadays nursing is people –oriented

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