ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 3 : Critical Thinking, Ethical Decision Making and the Nursing Process Questions
Question 1 of 5
During discussion with the patient and the patients husband, you discover that the patient has a living will. How does the presence of a living will influence the patients care?
Correct Answer: C
Rationale: Because living wills are often written when the person is in good health, it is not unusual for the patient to nullify the living will during illness. A living will does not make a patient legally unable to refuse basic life support. The physician may disagree with the patients wishes, but he or she is ethically bound to carry out those wishes. A power-of-attorney is not synonymous with a living will.
Question 2 of 5
Your older adult patient has a diagnosis of rheumatoid arthritis (RA) and has been achieving only modest relief of her symptoms with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). When creating this patients plan of care, which nursing diagnosis would most likely be appropriate?
Correct Answer: A
Rationale: Nursing diagnoses are actual or potential problems that can be managed by independent nursing actions. Self-care deficit would be the most likely consequence of rheumatoid arthritis. Anxiety and hopelessness are plausible consequences of a chronic illness such as RA, but challenges with self-care are more likely. Ineffective airway clearance is unlikely.
Question 3 of 5
You are writing a care plan for an 85-year-old patient who has community-acquired pneumonia and you note decreased breath sounds to bilateral lung bases on auscultation. What is the most appropriate nursing diagnosis for this patient?
Correct Answer: A
Rationale: Nursing diagnoses are not medical diagnoses or treatments. The most appropriate nursing diagnosis for this patient is ineffective airway clearance related to copious tracheobronchial secretions. Pneumonia and poor ventilation are not nursing diagnoses. Immobility is likely, but is less directly related to the patients admitting medical diagnosis and the nurses assessment finding.
Question 4 of 5
You are providing care for a patient who has a diagnosis of pneumonia attributed to Streptococcus pneumonia infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing process?
Correct Answer: A
Rationale: The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing action, such as maintaining a certain level of oxygen saturation in a patient with pneumonia. Providing fluids and avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an assessment.
Question 5 of 5
You are the nurse who is caring for a patient with a newly diagnosed allergy to peanuts. Which of the following is an immediate goal that is most relevant to a nursing diagnosis of deficient knowledge related to appropriate use of an EpiPen?
Correct Answer: A
Rationale: Immediate goals are those that can be reached in a short period of time. An appropriate immediate goal for this patient is that the patient will demonstrate correct administration of the medication today. The goal should specify that the patient administer the EpiPen. A 2-week time frame is inconsistent with an immediate goal.