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1.In the following situation, identify 5 human responses to actual or potential health problems that are identified nursing diagnoses. 

 

A 35-year-old woman has been admitted to the hospital for a breast biopsy and possible mastectomy. She tells the nurse she has known about the mass in her right breast for about nine months but had not seen her Primary Care Provider because she was frightened it may be cancerous. She paces the room, telling the nurse she has a 2-year-old son when needs to be able to care for. She is uncertain about what to expect if she should need surgery. The following morning, a frozen section reveals cancer, and she undergoes a modified radical mastectomy. Postoperatively, she is experiencing a great deal of incisional pain with edema and limited movement of her right arm. She will only glance at the surgical site with her dressing changes, and remarks about her appearance, “I look awful.” When the surgeon informs her that many of her lymph nodes were positive for cancer and she will have to undergo chemotherapy and radiation, she begins to cry. She expresses that her primary concern was no longer being attractive to her husband, but now her focus is on living and being able to care for her son. 

 

2. Case Study: Types of Nursing Actions 

A 60-year-old patient that has been hospitalized with heart failure has been receiving large doses of diuretics. The nurse notices that the patient has increased weakness, limp extremities, has become irritable and has a weak, rapid pulse. The nurse notifies the physician of her findings. The physician orders a serum electrolyte lab study. The results indicate hypokalemia, and the nurse notifies the physician, who then orders potassium supplements, daily serum electrolyte levels and a high potassium diet. The nurse administers the ordered medications and discusses the dietary order and the patient’s status with the dietician. The dietician meets with the patient and begins initial teaching of dietary intake of potassium. The nurse helps the patient choose high potassium foods from the daily menu and evaluates the patient’s ability to make correct food choices. The nurse also monitors the patient’s response to the potassium supplements with the daily lab results and her physical assessment. 

 

What are the independent, collaborative, and dependent functions that the nurse demonstrated in this situation? 

3.Match the phrases of the nursing process (letters) with the following descriptions (numbers). Answers may be used more than once. 

1. Assessment 

2. Diagnosis 

3. Planning 

4. Implementation 

5. Evaluation 

 

Analysis of data 
Priority setting  
Nursing interventions  
Data collection 
Identifying patient strengths  
Measuring patient achievement of goals 
Setting goals 
Identifying health problems 
Nursing interventions 
Modifying plan of care 
Documenting care provided 

 

4.The following are examples of nursing diagnoses. If the example is incorrectly written, please re-write it. 

Inability to turn related to traction. 
Restlessness and fatigue related to sleep pattern disturbances. 
Pain related to surgery. 
Ineffective individual coping related to inadequate support system as evidenced by consuming large amounts of alcohol, sleep disturbances, and not wanting to leave the house. 

 

5.Read the case history and write a three part nursing diagnosis that clearly describes the problem: 

A 50-year-old patient has been on prolonged bedrest due to a fractured pelvis. When he begins to ambulate, he develops the following signs and symptoms: SOB with exertion, he reports the inability to carry out his usual activities of daily living because he feels weak, tired, and his pulse remains elevated for more than 5 minutes after activity.  

6. Identify 4 guidelines that may be used in prioritizing interventions for nursing diagnoses. 

7. Identify how planned nursing interventions would differ between the following nursing diagnoses. 

Altered nutrition: less than body requirements related to anorexia 

Altered nutrition: less than body requirements related to difficulty in swallowing 

 

8. Identify the expected patient outcomes that are correctly written. Revise the ones that are not correct. 

The patient will recognize the importance of taking medications as prescribed. 
The patient can list the supplies needed to change a dressing by discharge. 
The patient will ambulate with the walker to the nurse’s station 3 times per day without assistance. 

  

9. A patient has a nursing diagnosis of ineffective airway clearance related to weak cough and incisional pain. Identify one nursing action indicated for this diagnosis that demonstrates an example of the interventions of 

Directly performing an activity for the patient. 
Assisting the patient. 
Supervising the patient. 
Patient education. 
Counseling the patient. 
Monitoring the patient. 

 

10. A patient has a nursing diagnosis of ineffective management of therapeutic regimen related to lack of knowledge regarding medication regimen, and a patient outcome of “Takes prescribed medications as directed…” 

When the nurse is teaching the patient about the medication regimen, the patient tells the nurse that he knows about the medications but he does not always have the money to refill the prescriptions. 

How would the nurse revise the care plan based on this information? 

11. Case Study: Kera Samos 

Kera is a 12-month-old female admitted to the pediatric floor with a history of high fever (104°F 

[40°C]), for 2 days. Kera’s father says that Kera was diagnosed with bilateral otitis media earlier 

in the week. Kera has been irritable and frequently inconsolable. She is refusing to eat or drink. 

The pediatrician decided to admit Kera to the hospital’s pediatric unit for evaluation of 

prolonged fever unresponsive to antibiotic and antipyretic therapy. 

Physical assessment findings include the following: erythematous (redness) of the palms 

and soles. She also has joint pain and mild nonpitting edema of her hands and feet. The nurse 

notes conjunctival infection bilaterally without exudate. Kera’s lips are red and cracked. Her 

tongue is strawberry red. Kera has nontender cervical lymphadenopathy (lymph nodes on the left 

side of her body are greater than 1.5 millimeters in diameter). Kera’s heart rate is regular without 

murmur and her lungs are clear bilaterally. Kera’s abdomen is soft and nontender with active 

bowel sounds all quadrants. There is no hepatosplenomegaly. Kera’s temperature is currently 

105.4°F (40.8°C) and she has been grimacing and crying throughout the examination. 

 

 

Critical Thinking Questions 

Kera has classic symptoms for what disease? 

 

What is the treatment for this disease? 

 

What are the priority nursing diagnoses at this time? 

 

List primary nursing interventions with rationales that correspond to the priority nursing 

diagnoses. 

 

What are key elements of discharge education related to Kawasaki disease? 

 

12. Case Study New Mom 

Dottie Clark is a 26-year-old G1P1 who gave birth 2 days ago and is to be discharged with her newborn baby boy today. Her husband is just home from the military and was not present for the birth of his son, but is here now for the discharge instructions. Mom is breastfeeding. 

 

What questions would the nurse want to know about this new family? 

 

How and when is discharge teaching initiated? 

 

What are the items that the nurse will cover during discharge teaching? 

 

How can the father of the baby participate in his son’s care? 

 

 

SCIENCE
HEALTH SCIENCE
NURSING