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Question One

A person has fallen over and is


unresponsive. Someone calls 911. What
additional assessments should be made?
Select all that apply.

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Question One Choices

1. Identify a witness to get an account of


the incident.
2. Search the patient for a list of
medications he or she may be taking.
3. Identify the patients healthcare provider.
4. Search for a cell phone for an ICE
contact.

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Question One Response

1. Identify a witness to get an account of


the incident.
2. Search the patient for a list of
medications he or she may be taking.
3. Identify the patients healthcare provider.
4. Search for a cell phone for an ICE
contact.

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Question One Rationales

Correct answers: Option 1. Witnesses may be able to


identify what caused the incident or what occurred
prior to the incident.
Option 2. Medications and a history card can help in the
plan of care for the patient.
Option 4. An ICE contact stands for In Case of Emergency.
The person the patient selected as a contact will be
able to provide information about that person. The
number also can be used to notify the contact of the
patients status.

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Question One Rationale

Option 3: Incorrect, because having the


name of the healthcare provider will not
affect interventions in this emergency
situation.

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Question Two

A patient who is being admitted to the


healthcare agency for a knee
replacement states, "I really am not sure
if I want this surgery." Select a nursing
diagnosis that best addresses
the patient's needs at this time.

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Question Two Choices

1. Deficient Knowledge related to upcoming


surgery
2. Anxiety related to impending surgery
3. Situational Low Self-Esteem related to
upcoming surgery
4. Hopelessness related to upcoming
surgery

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Question Two Response

1. Deficient Knowledge related to upcoming


surgery
2. Anxiety related to impending surgery
3. Situational Low Self-Esteem related to
upcoming surgery
4. Hopelessness related to upcoming
surgery

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Question Two Rationale

Correct answer: Option 2. The patient is


verbalizing concerns related to the surgery,
reflecting the nursing diagnosis of Anxiety.

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Question Two Rationales

Option 1: Incorrect, because the patient is not


stating incorrect information about the surgery
or asking questions about the procedure.
Option 3: Incorrect, because the patient is not
indicating a negative self-image.
Option 4: Incorrect, because the patient is not
suggesting that the surgery would do no good.

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Question Three

When a patient experiences an unexpected


respiratory arrest, the nurse will change
the care plan based on what step of the
nursing process?

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Question Three Choices

1. Evaluation
2. Nursing Diagnosis
3. Planning
4. Assessment

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Question Three Response

1. Evaluation
2. Nursing Diagnosis
3. Planning
4. Assessment

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Question Three Rationale

Correct answer: When a patient's condition


changes for the better or for the worse,
evaluation leads to review of the steps of the
nursing process. Evaluation will allow for
changes in the care plan to meet the changed
needs of the patient.

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Question Three Rationales

Option 2: Incorrect, because an example of a nursing


diagnosis for a patient who has respiratory arrest would
be: Ineffective Airway related to (whatever is the cause
of the respiratory arrest).
Option 3: Incorrect, because evaluation is the necessary
step that will lead to new planning and goals.
Option 4: Incorrect, because evaluation is what indicates a
need for reassessment due to client changes.
Reassessment may then result in changes in the care
plan.

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Question Four

Identify interventions for a patient who has


had a cardiac arrest? Select all that
apply.

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Question Four Choices

1. Monitor patients vital signs frequently.


2. Discuss the plan of care with the patient.
3. Identify family and friends to whom the patient
will be discharged.
4. Notify the healthcare provider of any changes
in vital signs, laboratory values, and test
results.
5. Discuss with the patient and family the
patients negative prognosis.

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Question Four Response

1. Monitor patients vital signs frequently.


2. Discuss the plan of care with the patient.
3. Identify family and friends to whom the
patient will be discharged.
4. Notify the healthcare provider of any
changes in vital signs, laboratory values,
and test results.
5. Discuss with the patient and family the
patients negative prognosis.

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Question Four Rationales

Correct answers: Option 1. An acute event like cardiac arrest will


require frequent vital sign monitoring. This will monitor the patient
for potential complications are recurrence of the event.
Option 2. The plan for what is going to happen now that the patient has
had a cardiac arrest needs to be discussed with the patient. This is
to ease their concerns and to answer questions they may have.
Option 3. Discharge plans, regardless of patients diagnosis, are always
an intervention. Initiating discharge plans as the patient is admitted
to the hospital saves time and money.
Option 4. Careful monitoring of the patient and the interventions will be
ordered by the healthcare provider. Reporting the results of the
interventions may lead to further interventions.

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Question Four Rationale

Option 5: Incorrect, because if the prognosis is


negative it is the responsibility of the healthcare
provider to discuss this with the patient and
family.

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Question Five

During the assessment part of the nursing


process, the nurse identifies the patient is
allergic to latex as evidence by an allergy band
and subjective data. Later the nurse writes on
the care plan: The patient will remain free from
exposure to latex during the hospital stay. To
what part of the nursing process did the nurse
contribute?

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Question Five Choices

1. Nursing Diagnosis
2. Planning
3. Intervention
4. Evaluation

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Question Five Response

1. Nursing Diagnosis
2. Planning
3. Intervention
4. Evaluation

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Question Five Rationale

Correct answer: Option 2. The statement is a goal


or planning step of the nursing process.

Pearson Nursing Lecture Series Copyright 2012 by Pearson Education, Inc.


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Question Five Rationales

Option 1: Incorrect, because a nursing diagnosis


would be related to the allergy identified, such
as Risk for Latex Allergy Response. This
statement is a goal or part of the planning step
of the nursing process.
Option 3: Incorrect, because interventions are
nursing actions, such as hanging a latex warning
sign outside the patient's room.
Option 4: Incorrect, because evaluation involves
reassessment of the patient to see whether the
goal has been met or whether new information
requires changes in the plan of care.

Pearson Nursing Lecture Series Copyright 2012 by Pearson Education, Inc.


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