Preview Extract
Chapter 7
1. Which of the following are examples of nursing activities that are considered part of the
independent functions of the nursing role?
Select all that apply.
1. Introduce oneself to the client and interview the client to collect data about physical health
status.
2. Talk with the client about his or her abilities to manage personal hygiene activities while in
the usual state of health at home.
3. Administer analgesic medication ordered by the health care provider.
4. Incorporate adaptive techniques into nursing care as recommended by occupational
therapy.
5. Teach a soon-to-be-discharged client about the medication regimen that the health care
provider has prescribed for the client after discharge.
Answer: 1. Introduce oneself to the client and interview the client to collect data about
physical health status.
2. Talk with the client about his or her abilities to manage personal hygiene activities while in
the usual state of health at home.
Rationale:
Introduce oneself to the client and interview the client to collect data about physical health
status. These activities are included in assessment, which is an independent activity that
nurses may perform, based on their education and skills. Talk with the client about his or her
abilities to manage personal hygiene activities while in the usual state of health at home. This
activity is part of the assessment process, which is an independent activity that nurses may
perform, based on their education and skills. Administer analgesic medication ordered by the
health care provider. This is an example of a dependent activity, since the medication is
prescribed by the health care provider and administered by the nurse. Incorporate adaptive
techniques into nursing care as recommended by occupational therapy. This is an
interdependent activity, since the nurse will be working in coordination with another health
team member. Teach a soon-to-be discharged client about the medication regimen that the
health care provider has prescribed for the client after discharge. This is an interdependent
activity, since the nurse will be teaching the client about medications prescribed for use by
the health care provider.
2. The nurse is caring for a 70-year-old client who was just admitted to an inpatient
rehabilitation center. The client had required total parenteral nutrition for several days, but
recently resumed and is tolerating a regular diet. She has another 4 days left in a course of
intravenous antibiotics to complete treatment of a positive central line culture. When
performing nursing activities typical of dependent role functions, the nurse would:
1. Administer the antibiotics prescribed by the health care provider.
2. Request that the health care provider order a consult with social work and speech and
language therapy because the client states that her dentures no longer fit properly and she
cannot chew properly.
3. Interview the client to assess whether she needs assistance with getting out of bed.
4. Ask the nursing assistant to demonstrate to the client how to operate the call system.
Answer: Administer the antibiotics prescribed by the health care provider.
Rationale:
The nurse is administering medication prescribed by the health care provider, which is a
dependent activity. Assessing that the client has a need that requires further assessment by
other health care members and communicating to the team member who is in the position to
assure that the appropriate disciplines are involved in the client's care is an example of an
interdependent activity. Assessing that the client needs assistance with getting out of bed is an
independent activity that nurses may perform, based on their education and skills. Asking the
nursing assistant to demonstrate to the client how to operate the call system is an independent
activity that nurses may perform, or delegate, based on their and the delegate's education and
skills.
3. Please choose from the following statements those that describe interdependent nursing
activities.
Select all that apply.
1. The nurse who is creating a care plan consults with the physical therapist to identify the
most appropriate transfer techniques to use in assisting a newly admitted client who has
mobility problems at baseline and incorporates this information into the care plan.
2. The nurse notifies the unit social worker when the mother of a toddler who just admitted to
the unit requests to stay with the toddler overnight with her two other children, because she
cannot identify any family or friends who might be able to care for them.
3. The nurse assesses an infant's hydration.
4. The nurse administers the type and amount of intravenous fluid that the health care
provider ordered.
5. The nurse evaluates whether the goals of the care plan have been met.
Answer: 1. Consulting with the physical therapist to identify the most appropriate transfer
techniques to use in assisting a newly admitted client who has mobility problems at baseline
and incorporating this information into the care plan.
2. Notifying the unit social worker when the mother of a toddler who just admitted to the unit
requests to stay with the toddler overnight with her two other children, because she cannot
identify any family or friends who might be able to care for them.
Rationale:
The nurse who is creating a care plan consults with the physical therapist to identify the most
appropriate transfer techniques to use in assisting a newly admitted client who has mobility
problems at baseline and incorporates this information into the care plan. This is an
interdependent activity, since the nurse is coordinating and planning care with a member of
another discipline, the physical therapist, to be sure the client's baseline mobility, safety, and
self-esteem needs are addressed appropriately. The nurse notifies the unit social worker when
the mother of a toddler who just admitted to the unit requests to stay with the toddler
overnight with her two other children, because she cannot identify any family or friends who
might be able to care for them. This is an interdependent activity, since the nurse has
recognized that this family may need assistance in coping with this hospitalization, and
recognizes that the social worker is best qualified to work with the family around this issue.
The nurse assesses an infant's hydration. Assessment of hydration is an independent nursing
action. The nurse administers the type and amount of intravenous fluid that the health care
provider ordered. Administering intravenous fluids is an example of a dependent activity that
the nurse carries out according to the health care provider's orders. The nurse evaluates
whether the goals of the care plan have been met. Evaluating the goals of a care plan is an
example of a independent nursing action.
4. When asking a patient if a pain medication provided a few hours ago has been effective,
the nurse is using which step of the nursing process?
1. Evaluation
2. Assessment
3. Planning
4. Implementation
Answer: Evaluation
Rationale:
Evaluation focuses on a patient’s behavioral changes and compares them with the criteria
stated in the objectives. It consists of both the patient’s status and the effectiveness of the
nursing care. Both must be evaluated continuously, with the care plan modified as needed.
Evaluation is ongoing through all phases of the nursing process. As the nurse works with a
patient, the patient’s responses to the nursing interventions are appraised to determine if the
desired outcomes (objectives) have been achieved.
5. The nursing instructor knows that further education is needed when the student states:
1. “Evaluation follows implementation and precedes planning.”
2. “Assessment precedes nursing diagnosis and outcome identification.”
3. “Planning follows assessment and precedes evaluation.”
4. “Planning follows nursing diagnosis and outcome identification and precedes
implementation.”
Answer: “Evaluation follows implementation and precedes planning.”
Rationale:
The correct order is assessment, diagnosis, planning, implementation, and evaluation.
6. The nurse has completed a comprehensive assessment of a 16-year-old client who has been
admitted for treatment for presumptive pelvic inflammatory disease. The client reported that
she has been living on the streets with a 27-year-old male. She is curled up in the fetal
position in bed, and when asked about her pain level, she cries out that she is in severe pain,
that is “way over the top” of a 1-to-10 pain scale. She pulls away and flinches when any part
of her body is touched. She is febrile and tachycardic. She has been examined and had all
necessary labs sent off from the emergency department, and IV antibiotics were started. Since
the client has already begun definitive medical treatment for her presumed infection, the
nurse identifies the nursing diagnosis of acute pain related to possible pelvic inflammatory
disease, and decides that this is the highest priority to address at this time. The appropriate
outcome for this nursing diagnosis is:
1. The client's comfort will be achieved and maintained.
2. The client will be discharged to a safe living environment.
3. The client's infection will be eradicated.
4. The client will be reunited with her parents.
Answer: The client's comfort will be achieved and maintained.
Rationale:
Achieving and maintaining comfort addresses the nursing diagnosis of acute pain related to
possible pelvic inflammatory disease identified by the nurse. The other outcomes do not
address this nursing diagnosis but may well be considered as a desired outcome for another
nursing diagnosis for this client.
7. During an assessment, the nurse notices that a patient hesitates to answer a health history
question and states, “You are going to think poorly of me if I answer that truthfully.” The
nurse encourages the patient to be honest. Which of the following skills is the nurse using at
this time?
1. Affective
2. Cognitive
3. Psychomotor
4. Emotional
Answer: Affective
Rationale:
The nurse is encouraging the patient to engage in full disclosure and demonstrates
nonjudgmental behavior, which is a characteristic of the affective skill needed to conduct a
comprehensive nursing assessment. Cognitive skills are used when determining which
assessment questions or techniques are needed to identify potential patient problems.
Psychomotor skills are those skills used when conducting a physical assessment and include
percussion and palpation. Emotional skills are not utilized when conducting a nursing
assessment.
8. While assessing a female client from the Middle East, the nurse observes that the client
makes no eye contact, and answers questions by head nodding, or with only a few words. The
nurse’s entry into the client’s record indicates that the client “appears to be frightened.” This
is an example of:
1. Personal interpretation.
2. Objective data.
3. Subjective data.
4. Nursing diagnosis.
Answer: Personal interpretation.
Rationale:
This is the nurse’s personal interpretation of the client’s behavior. It has not been validated
with the client. These behaviors may indicate a number of possibilities, depending on
physical, mental and emotional status and cultural and social norms, for example. A
description of the client’s behavior such as “makes no eye contact” would be objective data.
A direct quotation from the client would be subjective data. This is not a nursing diagnosis,
since it has not been validated with the client.
9. The client tells the nurse that everything “tastes funny” since starting a new medication,
making eating unpleasant. The nurse has given this medication to other clients, and has not
heard this complaint from any of them. The nurse re-checks the drug information resource to
learn whether this is a known side effect of the medication, and reads that it is. This
information may be helpful in making a nursing diagnosis and in determining how best to
address this problem. Subjective data for this client includes:
1. The client tells the nurse that, since starting a new medication, everything “tastes funny.”
2. The nurse has never experienced other clients who have taken this medication report this.
3. The nurse re-checks the drug reference to learn whether this is a known side effect of the
medication.
4. The nurse reads that this medication can cause a metallic taste in some clients.
Answer: The client tells the nurse that, since starting a new medication, everything “tastes
funny.”
Rationale:
The statement by the client is subjective data, since the client tells the nurse something that
only the client, and not the nurse, can perceive. The nurse's prior experience with this
medication is not data about the client. Re-checking the drug reference is an example of the
nurse obtaining factual information about the medication, and not data about the client. That
this medication can cause a metallic taste in some clients is an example of factual information
about the medication, and not data about the client.
10. Identify which of the following are nursing diagnoses.
1. High risk for delayed maternal-infant bonding due to maternal-infant separation (infant
transferred) to newborn intensive care unit in a pediatric hospital 30 miles away from mother.
2. Hypertension
3. Appendicitis
4. Crohn’s disease
Answer: High risk for delayed maternal-infant bonding due to maternal-infant separation
(infant transferred) to newborn intensive care unit in a pediatric hospital 30 miles away from
mother.
Rationale:
“High risk for delayed maternal-infant bonding due to maternal-infant separation (infant
transferred) to newborn intensive care unit in a pediatric hospital 30 miles away from
mother” is an example of a nursing diagnosis. The statement indicates a clinical judgment
that this new mother−baby couplet is more at risk to experience a delay in bonding than other
mother−baby couplets, because of the baby's transfer away from the mother. Hypertension,
appendicitis, and Crohn’s disease are examples of medical diagnoses.
11. Identify the nursing diagnoses in the following problem list:
Select all that apply.
1. High risk for knowledge deficit related to infant safety as evidenced by mother leaving crib
rail down
2. Sleep pattern disturbance related to hospital environment and routines
3. Neonatal abstinence syndrome
4. Sleep apnea
5. Gestational diabetes
Answer: 1. High risk for knowledge deficit related to infant safety as evidenced by new
mother leaving crib rail down
2. Sleep pattern disturbance related to hospital environment and routines
Rationale:
“High risk for knowledge deficit related to infant safety as evidenced by new mother leaving
crib rail down” is a nursing diagnosis. “Sleep pattern disturbance related to hospital
environment and routines” is a nursing diagnosis. Neonatal abstinence syndrome is a medical
diagnosis and therefore a collaborative problem. Sleep apnea is a medical diagnosis and
therefore a collaborative problem. Gestational diabetes is a medical diagnosis and therefore a
collaborative problem.
12. One way the nurse can differentiate between nursing diagnoses and collaborative
problems and identify the nursing diagnoses is to think about whether the nurse can address
the problem by establishing a plan of interventions that:
1. All may be prescribed by a nurse.
2. Require a health care provider's order.
3. Require further assessment by a speech therapist.
4. Require intervention by a respiratory therapist.
Answer: All may be prescribed by a nurse.
Rationale:
When a problem can be addressed by interventions that all may be prescribed by a nurse, it is
a nursing diagnosis. Because health care provider's orders, a speech therapist, or a respiratory
therapist are needed to address the other problems, these are not problems that can be
addressed independently by the nurse, so they represent collaborative problems.
13. Identify the step in the nursing process that interfaces with the statement that critical
thinking enhances the ability to better understand someone else.
1. Assessment
2. Nursing diagnosis and outcome identification
3. Planning
4. Implementation
Answer: Assessment
Rationale:
The goal of assessment is to learn as much as possible about the client within the context of
the nurse−client relationship. One characteristic of the nurse−client relationship is the nurse’s
continuous focus on better understanding the client. There are other aspects of critical
thinking that interface more closely with the other steps listed.
14. From the following list, choose the characteristic of critical thinking that interfaces with
nursing diagnosis.
1. Identify potential and actual problems.
2. Get a better understanding of someone else.
3. Make decisions about an action.
4. Increase the likelihood of obtaining good results.
Answer: Identify potential and actual problems.
Rationale:
Identifying potential and actual problems is analogous to identifying nursing diagnoses,
potential and actual. The other characteristics are not reflective of the interface between
critical thinking and nursing diagnosis, but are related to other steps of the nursing process.
15. The practice of critical thinking empowers the nurse to recognize important cues in a
given situation, and to respond to these quickly to adapt interventions to optimize their
effectiveness and likelihood of producing a good outcome. This aspect of critical thinking:
1. Is similar to the way that a skilled nurse incorporates continued assessment and evaluation
into practice, adapting the care plan in response to its effectiveness or change in client status.
2. Is another term for the nursing process.
3. Means that there is only one correct solution to a problem.
4. Indicates that critical thinking and the nursing process are unrelated.
Answer: Is similar to the way that a skilled nurse incorporates continued assessment and
evaluation into practice, adapting the care plan in response to its effectiveness or change in
client status.
Rationale:
This is similar to the way that a skilled nurse incorporates continued assessment and
evaluation into practice, adapting the care plan in response to its effectiveness or change in
client status. The nursing process itself is cyclical, dynamic, and flexible in response to
ongoing assessment of client needs and effectiveness of interventions, and is similar to the
characteristic of critical thinking in the statement. Critical thinking and the nursing process
are not synonymous; critical thinking enhances and complements the nursing process, but is
not identical to it. Critical thinking does not mean that there is only one correct answer to a
problem; rather it demands that the nurse looks at information related to the question from
many different viewpoints to identify the next step. Critical thinking and the nursing process
are not unrelated, but have some similarities; critical thinking enhances and complements the
nursing process.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
