The LPN/LVN contributes to nursing diagnoses by
1. Identifying client strengths
2. Naming health problems that can be prevented
3. Understanding the nursing diagnoses identified by the RN
4. Developing a list of independent nursing interventions
5.
3
Rationale 1: Identifying client strengths is an RN function
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In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would:
a. Omit the otoscopic examination if the child has a fever. b. Pull the ear up and back before inserting the speculum. c. Ask the mother to leave the room while examining the child. d. Perform the otoscopic examination at the end of the assessment.
The nurse is assessing a client's spiritual and belief patterns and is currently asking the client about participation in organized religion. The nurse is on which step of the HOPE assessment with this client?
1. H 2. O 3. P 4. E
A nurse has referred a client to the managed care service provided by the hospital. What is the purpose of this referral?
a. To confirm that care options chosen are the least expensive possible b. To coordinate the care provided by professional specialists c. To keep the focus on the individual patient's unique needs d. To review care to eliminate unnecessary services
When obtaining vital signs, a nursing assistive personnel is concerned that the heart rate of 56 is too low for a 23-year-old client who has been training for a marathon. The nurse explains that:
1. A low heart rate is normal in well-conditioned athletes 2. The health care provider needs to be notified immediately 3. The heart rate needs to be rechecked before taking any action 4. The heart rate could be caused by hyperthyroidism