Question

Questions 16-25 refers to the following scenario. Please circle the most appropriate answer
Mr. Ragbir 65-year-old male client has been diagnosed with diabetes mellitus X 12 years but is controlled with insulin therapy. He was admitted via clinic to the ward for minor surgery this morning to remove a cyst on his right upper thigh. Sandra a registered nurse has been assigned to care of Mr. Ragbir postoperative.

Question 16.

Sandra hopes to develop a therapeutic relationship with her client. Which action would indicate that she is knowledgeable about the phases of the helping relationship?
i. Before meeting Mr. Ragbir she reviews his medical and nursing history
ii. She let Mr. Ragbir know when the relationship will end
iii. She encourages and help Mr. Ragbir to express feelings about his health
iv. She identifies and priorities his care problems

Question 16.

a. i only

b. ii and iii only

c. ii and iv only

d. all the above

Question 17.

When assessing Mr Ragbir, Sandra is cognizant that Assessment involves several steps. These include;
i. Validating the data
ii. Organizing data
iii. Recording or reporting data
iv. Making initial inferences or impressions
v. Collecting data from a variety of sources
vi. Categorizing or identifying patterns in the data

Question 17.

a. i, iii and v

b. i ii, iii and iv

c. ii, iii iv and v

d. all the above

Question 18.

At which stage(s) will Sandra confirm that the data is accurate and factual
i. Validating the data
ii. Organizing data
iii. Recording or reporting data
iv. Making initial inferences or impressions
v. Collecting data from a variety of sources
vi. Categorizing or identifying patterns in the data

Question 18.

a. i, only

b. i and v

c. ii, iii iv and v

d. all the above

19. On return from operating theatre, Sandra assesses Mr. Ragbir and documents her findings. Both objective and subjective information have been obtained during the assessment. Which of the following is classified as objective data?

a. Pain in the right upper thigh

b. Elevated blood sugar level of 150mg/dl

c. Fear of a post-operative scar

d. Feelings of hunger

20. Which of the following would be the most appropriate nursing diagnosis that Sandra should include in her initial care plan?

a. Pain related to surgical incision

b. Activity intolerance related to surgical procedure

c. Self-care deficit related to immobility

d. Knowledge deficit related to disease process

21. When reviewing the development of Nursing Process, Sandra is cognizant that nursing diagnosis categories include all, except

a. Actual

b. Risk

c. Possible

d. Syndrome

22. When formulating the nursing diagnoses, Sandra recognizes that?

a. The diagnosis communicates specific health care needs about the client.

b. The diagnosis must remain constant during the client’s hospitalization.

c. The diagnosis should always include the problem, the related contributing conditions and evidence.

d. The diagnosis should identify a “cause and effect” relation.

23. All of the following are critical elements in the planning phase except;

a. The identification and prioritizing of problems

b. The setting realistic goals and expectation

c. The determination of appropriate nursing intervention and recognizing when collaboration is needed

d. The determination and reference to a disease or pathological state of the client

Answer 1

16. D- All the above.

17. A- I,3 and 5.

Assessment involve s validating, Organizing, collecting data from various sources.

18. A- 1 Only,

Validating the data confirms that the data is accurate and factual.

19. B- Elevated blood sugar level of 150 mg/dl.

20. D- Knowledge deficit related to disease process.

21. C- Possible.

22. A- The diagnosis communicates specific health care needs about the client.

23. D- the dertimination and reference to a disease or a phatolohical state of the client.

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