NUR 3212 Final Exam Review Latest

1 NUR 3212 Final Exam Review Latest Actual Exam Questions with Correct Detailed Answers (Verified Answers) Graded A+

A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes, usually twice or more." The patient had an episode of diarrhea 1 week ago. She weighs 300 lb. and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination.(Select all that apply.)

• Age 42
• Dysuria
• Difficulty performing perineal hygiene
• Nocturia
• Episode of diarrhea - Correct Answer - 2, 4. The assessment findings are individual

data elements that form a pattern revealing a nursing diagnosis. The assessment findings include dysuria and nocturia. The patient's age is a descriptive characteristic of the patient. The episode of diarrhea is a historical finding that predisposed the patient to having perineal hygiene needs, but is not an assessment finding for the diagnosis.

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)

• Offer frequent skin care because of Impaired Skin Integrity
• Risk of Infection
• Chronic Pain related to osteoarthritis
• Activity Intolerance related to physical deconditioning
• Lack of Knowledge related to laser surgery - Correct Answer - 2, 4. Option 2 is a "risk

for" diagnosis and does not have related factors. Option 4 has related factors that a nurse can manage with etiology-specific interventions. Option 1 identifies a nursing 1 / 4

2 intervention instead of a problem. Option 3 has a related factor of a medical diagnosis, which a nurse cannot treat directly. Option 5 describes a treatment procedure and not the patient's response to the procedure.

Which of the following best describe a collaborative health problem? (Select all that apply.)

• An actual or potential physiological complication that nurses monitor to detect the

onset of changes in a patient's health status

• The language medical practitioners use to communicate a patient's health problem

and associated treatments and response

• A diagnostic label that classifies a patient's response to illness so that all nurses can

be familiar with a specific patient's health care needs

• A language used by health care providers to communicate and consider each other's

unique perspective, so they can better manage the multiple factors that influence the health of individuals

• A diagnosis that provides clear direction as to the type of nursing interventions nurses

are licensed to provide independently - Correct Answer - 1, 4. Option 2 describes a medical diagnosis, and options 3 and 5 describe a nursing diagnosis. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status. Nurses intervene in collaboration with personnel from other health care disciplines to manage collaborative problems.

Which of the following is a diagnostic error involving identification of a goal of care rather than a patient need?

• Patient obtains social support care related to caregiver stress
• Fear related to open-heart surgery
• Acute Pain related to splinting of incision
• Impaired Family Coping related to insufficient caregiver support - Correct Answer - 1.

A nursing diagnosis must identify a patient response to a health care problem and not the goal of care. Achieving social support would be a goal of care in a plan of care for relieving caregiver stress. Answers 2, and 3 are diagnostic errors: 2 makes the related factor a surgical procedure, 3 uses a symptom as a related factor. 4 is a correctly worded nursing diagnosis.

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3 A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order.

• Consider the context of patient's health problem and select a related factor.
• Review assessment data, noting objective and subjective clinical information.
• Cluster clinical data elements that form a pattern.
• Identify appropriate assessment findings for diagnosis.
• Identify a nursing diagnosis. - Correct Answer - 2, 3, 5, 1, 4

A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced movement of lower leg, reduced range of motion in left knee, and difficulty turning in bed without assistance. This data set is an example of:

• Collaborative data set.
• Diagnostic label.
• Related factors.
• Data cluster - Correct Answer - 4. A data cluster is the data elements about a patient

that form a meaningful pattern, in this case a pattern of impaired mobility

A nurse reviews data gathered regarding a patient's response to a diagnosis of cancer.The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in? (Select all that apply.)

• Data collection
• Data clustering
• Data interpretation
• Making a diagnostic statement
• Goal setting - Correct Answer - 2, 3 and 4. Data interpretation involves analyzing

assessment findings and then involves placing a label on a data pattern or cluster to clearly identify the patient's response to health problems. Critical thinking is necessary.The interpretation of data clusters or patterns leads to the selection of various nursing diagnoses that may apply to a patient. It is important to compare the data in a cluster with the data standards for a diagnosis to come to a reasoned conclusion in making an 3 / 4

4 accurate nursing diagnosis. In this case the nurse did not gather additional data, so avoidance of an error in data collection is not a correct response. Goal setting is not part of the nursing diagnosis process.

A nurse is assigned to five patients, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? (Select all that apply.)

• The nurse directs the assistive personnel to obtain a set of vital signs on the patient

returning from the diagnostic procedure.

• The nurse directs the patient care technician to go to the patient in pain and to

reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient.

• The nurse directs the patient care technician to set up meal trays for patients.
• The nurse directs the patient care technician to gather a history from the newly

admitted patient about his medications.Correct Answer - 2, 3, The nurse can delegate repetitive, noninvasive tasks such as vital signs on a stable patient, assisting a mobile patient with ambulation, and setting up meal trays. It is inappropriate for the nurse to delegate aspects of the nursing process, such as collecting a medication history. The nurse also should not delegate vital signs if a patient might be unstable from returning from a diagnostic test.

A nurse working the evening shift has five patients and is teamed up with assistive personnel. One of the assigned patients has just returned from surgery, three others are stable and resting, and one has requested a pain medication. The patient in pain has two analgesics ordered prn for pain and has been using cold applications on his surgical site for pain relief. The last time an analgesic was given was 4 hours ago. The patient is scheduled for a physical therapy visit in 2 hours. Which of the following demonstrate good clinical decision-making during intervention? (Select all that apply.)

• The nurse reviews the options for pain relief for the patient.
• The nurse assesses whether the prn medication, ordered every 4 to 6 hours and last

given 4 hours ago, is effective and whether a new type of medication is needed.

• The nurse reviews the policy and procedure for the cold application.
• The nurse consider - Correct Answer - 1, 2, 4. The nurse exercises critical judgment

in decision making by reviewing the set of all possible nursing interventions for a

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