ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 3 : The Nursing Process Questions
Question 1 of 5
The nurse is developing a care plan for a for a client who has had a stroke and is unable to assist with care at this time. Which Which problem would the nurse deem deem a top priority?
Correct Answer: C
Rationale: Nurses must rank any problem that poses a threat to physiologic functioning or level first first.. For example, a nursing diagnosis such as for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a breathing as a nursing intervention may life- life-threatening.. The second than life other is the second-level.. level and higher.. This relates to Maslow's hierarchy..
Question 2 of 5
Who should be involved in establishing specific and realistic outcomes so the client does not become frustrated in trying to achieve them?
Correct Answer: A
Rationale: The nurse includes the client and family in establishing outcomes. Outcomes are specific and realistic, so the client can attain them and not become frustrated, and measurable, so the nurse can reliably determine to what extent the client is meeting the goals. The physician, CNA, and case management do not play a role in the development of nursing outcomes.
Question 3 of 5
The nurse is prioritizing the care of a client who has a diagnosis of uncontrolled diabetes and may have the left foot amputated related to a nonhealing ulcer. What need would the nurse place at the lowest level of Maslow's hierarchy while prioritizing this client's care?
Correct Answer: D
Rationale: Self-actualization needs are the fifth and last level of Maslow's hierarchy. Physiologic needs are the first level, safety and security needs are the second level, and love and belonging needs are the third level.
Question 4 of 5
The nurse has developed a plan of care for a client who is having a surgical procedure and is at risk for the development of a pneumonia for a surgical diagnosis.. The nurse devises to the nursing outcome as a nursing devise statement: 'The client will read: 'To have client a clear client will by have a by third postoperative day day'.' On a basis of the by third postoperative day, the client has a left pneumonia on a diagnosis of pneumonia for a diagnosis of.. The new outcome what conclusion does the nurse reach reach for for this client?
Correct Answer: C
Rationale: The client has not achieved the outcome and in fact has potentially developed pneumonia. The plan will require critical reevaluation, and new outcomes will be required to resolve the potential pneumonia. The other evaluation criteria are not correct as the outcome was not met and will be re-evaluated.
Question 5 of 5
The nurse is reviewing the concept care map for a client with multiple medical problems. What significance does the concept care map have in relation to the client's plan of care?
Correct Answer: C
Rationale: The significance of the concept map is that it is a means for nurses to consider all of the client's problems (nursing and medical) and develop a plan for the treatment of those problems. A concept map may be reviewed by a health care provider, but it does not provide guidance for health care providers to develop a client's treatment plan. A concept map is an alternate to nursing care plans but is not considered the best method for evaluating the plan of care. A concept map is not a student version of a client's nursing care plan. It does assist a student in assessing what is known about a client and what information is still needed.