Fundamental Nursing Skills and Concept 10th Edition Timby
Fundamental Nursing Skills and Concept 10th Edition Timby
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Chapter 2- Nursing Process
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
| 1. | A client reports to a health care facility with complaints of abdominal pain and vomiting. The client’s wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data? | |
| A) | Client’s friends | |
| B) | Client’s wife | |
| C) | Client himself | |
| D) | Test reports | |
| Ans: | C | |
| Feedback: | ||
| As the client is in a conscious state, he himself is the primary source of information since he can give firsthand information. The client’s wife, friends, and test results would be the secondary sources of data. | ||
| 2. | A client with HIV has been admitted to a health care facility. Which of the following nursing diagnoses should be of the highest priority, keeping in mind the client’s condition? | |
| A) | Risk for activity intolerance | |
| B) | Risk for ineffective coping | |
| C) | Risk for infection | |
| D) | Risk for imbalanced nutrition | |
| Ans: | C | |
| Feedback: | ||
| Clients with HIV have decreased immunity and are prone to infections. Infection in a client with HIV is life-threatening, because it makes the client vulnerable to other infections, and also impairs his or her already weakened immune functions. Clients with HIV may not have problems with other activities and food. They may often feel depressed, but this is not the highest priority. | ||
| 3. | A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data? | |
| A) | Blood pressure | |
| B) | Nausea | |
| C) | Heart rate | |
| D) | Respiratory rate | |
| Ans: | B | |
| Feedback: | ||
| Subjective data are those that the client can feel and describe. Nausea is subjective data, as it can only be described and not measured. Blood pressure, heart rate, and respiratory rate are measurable factors and are therefore objective data. | ||
| 4. | A client who has to undergo a thyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan? | |
| A) | Risk for impaired physical mobility due to surgery | |
| B) | Ineffective denial related to poor coping mechanisms | |
| C) | Disturbed body image related to the incision scar | |
| D) | Risk of injury related to surgical outcomes | |
| Ans: | C | |
| Feedback: | ||
| The client is concerned about the surgery scar on his neck, which would disturb his body image; therefore, the appropriate diagnosis should be disturbed body image related to the incision scar. Risk for impaired physical mobility may be present after surgery, but is not related to the concerns expressed by the client. Likewise, ineffective denial related to poor coping mechanisms and injury related to surgical outcomes are also not related to the client’s concern. | ||
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