Study Guide for Fundamentals of Nursing The Art and Science of Nursing Care

CHAPTER 13

PRACTICING FOR NCLEX

MULTIPLE CHOICE QUESTIONS

1.c 2.a 3.d 4.c 5.d

ALTERNATE-FORMAT QUESTIONS

Multiple Response Questions

1.b, c, e, f

2.c, d, f

3.a, b, d

4.c, d, e

5.a, b, d

DEVELOPING YOUR KNOWLEDGE BASE

FILL-IN-THE-BLANKS

1.Collaborative

2.Cues

3.Standard or norm

4.Data cluster

5.Nursing diagnosis

6.Inability to accept the death of newborn child

7.Desire for a higher level of wellness, an effective

present status or function

8.Syndrome

MATCHING EXERCISES

1.c 2.a 3.b 4.d 5.a

6.c 7.d

CORRECT THE FALSE STATEMENTS

1.False—nursing diagnoses

2.False—Nursing diagnoses

3.False—standard or norm

4.True

5.False—cluster of significant data

6.True

7.False—etiology

8.True

9.True

10.True

11.False—analyzes patient data

12.False—risk diagnosis

SHORT ANSWER

1. a.Using legally inadvisable language
   b.X
   c. Identifying responses not necessarily unhealthy
   d.X
   e.Both clauses say the same thing.
   f. X
   g.Including value judgment
   h.Identifying responses not necessarily unhealthy
   i. X
   j. Including medical diagnosis
   k.Identifying problems as signs and symptoms
   l. Reversing clauses

m.X

n.Both clauses say the same thing.

o.Identifying problems/etiologies that cannot be

altered

p.Both clauses say the same thing.

q.X

r. Writing diagnosis in terms of needs

2.Sample answers:

a.Were you able to pass urine this morning? Did

you drink the fluids we brought you?

b.Do you feel like talking to other patients who are

undergoing the same treatment? Would you like

to see your family today?

c. Do you feel helpless to put your life back in order?

Are you overwhelmed by the changes in your life?

d.Were you able to get some sleep last night? Did

the noise on the unit keep you awake?

3. a.No problem: Reinforce patient’s health habits
   and patterns; initiate health promotion activities
   to prevent disease or illness or promote higher
   level of wellness.
   b.Possible problem: Collect more data to confirm
   or rule out suspected problem.
   c. Actual or potential nursing diagnosis: Unable to
   treat because patient denies problem or refuses
   treatment; begin planning, implementing, and
   evaluating care designed to prevent, reduce, or
   resolve problem.
   d.Clinical problem other than nursing diagnosis:
   Consult with appropriate healthcare professional
   and work collaboratively on problem; refer to
   medicine.
   4.Sample answers:
   a.An infant who is below the normal growth stan-
   dards for his age group may be experiencing
   “failure to thrive.”
   b.A mother who has a history of mental illness
   shows little or no interest in her baby.
   c. A patient placed in a nursing home by her son
   becomes incontinent without a physical cause.


4. a.Are my data accurate and complete?
   b.Has the patient or the patient’s surrogates (if able
   to do so) validated that these are important
   problems?
   c. Have I given the patient or the patient’s
   surrogate an opportunity to identify problems
   that I have missed?
   d.Is each diagnosis supported by evidence? Might
   these cues signify a different problem or diagnosis?
   e.Have I tried to identify what is causing the actual
   or potential problem and what strengths/resources
   the patient might use to avoid or resolve the
   problem?


5. a.In the presence of known problems, nurses must
   predict the most common and most dangerous
   complications and take immediate action to pre-
   vent them or manage them in case they cannot
   be prevented.

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ANSWER KEY 343

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