Which statement is true regarding the nursing process

Question 1 of 10

A nurse is performing an initial assessment for a client. Which of the following would be considered subjective information received during the assessment?

• The client's blood pressure increases when the provider enters the room
• The client rates pain at a level of 6 on the numeric rating scale
• The client weighs 186 pounds
• The client has a pinpoint rash on the face and trunk

Question 2 of 10

When planning nursing care for a client, objectives should be SMART. Specific, measurable, action-oriented, realistic, and timely. Which example best describes an outcome that is measurable?

• The client's family will agree to the methods of treatment
• The client will have control of his back pain
• The client will verbalize feelings about her diagnosis
• The client will ambulate to the end of the hallway within 2 days

Question 3 of 10

A nurse is caring for a 2-day-old infant who requires phototherapy for treatment of jaundice. Which information would be included as part of the nurse’s subjective assessment?

• The infant's weight at birth
• The parent had jaundice as a newborn
• The amount of the infant's last feeding
• The most recent bilirubin level

Question 4 of 10

A nurse is assessing a client who is being admitted to the hospital from home for knee surgery. Which part of the assessment would be included with an admission assessment but not with a routine focused assessment?

• Assessment of the cause of the client's knee injury
• Assessment of the client's pain
• Assessment of the client's vital signs
• Assessment of knee range of motion

Question 5 of 10

The nurse is planning care for a client and prioritizes health promotion and accident prevention. Which of the following age groups does this client most likely fall into, with accidents and injuries from recreational activities as the main health concern?

• Adolescence
• Middle adulthood
• School age
• Early adulthood

Question 6 of 10

A nurse is planning care for a postpartum client with the goal of preventing the development of a DVT. Which of the following should be included? Select all that apply.

• Compression hose
• Clear liquids
• Hourly calf measurements
• Cross the client's legs when she sits up to a chair
• Ambulate frequently

Question 7 of 10

A nurse started working in an ethnically diverse clinic. Which actions could the nurse implement to deliver culturally competent care? Select all that apply.

• The nurse learns about the ethnic backgrounds of clients at the clinic
• The nurse asks clients about their preferences for care
• The nurse uses family members when possible to serve as interpreters
• The nurse avoids making assumptions based on a client's appearance
• The nurse incorporates hand gestures when teaching clients

Question 8 of 10

A nurse is caring for a client who has been sexually abused. Which of the following interventions should the nurse implement to establish rapport and to demonstrate safety?

• Delay treatment until the client can talk about the situation
• Respond to shocking information by ignoring or disregarding the account
• Assess the client's stress level before performing procedures
• Let the client spend time alone in a quiet area

Question 9 of 10

A nurse is giving report about the nurse’s clients to the oncoming group of nurses who are taking over the next shift. The nurse uses the clients’ care plans to organize report information before presenting it to the group. Which would best describe the purpose of using a care plan for giving shift report?

• Using healthcare informatics to demonstrate trends in the client's vital signs over the past week
• Organizing the information from different disciplines so that oncoming nurses can read it
• Having a reference for the client's demographic data
• Using current and appropriate information to share about the client's condition and complications

Question 10 of 10

A nurse has assessed a client during the admission and is formulating a nursing care plan based on the provider’s orders and results of the assessment. Which of the following is a true statement regarding a nursing care plan?

• A nursing diagnosis focuses on finding a solution to the patients problem
• A nursing diagnosis must be validated by the provider
• A nursing care plan guides the nurse for how to provide care for the client
• A nursing diagnosis is based on a judgment call made by the nurse about the client's condition.

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