NURSING TEST TAKING STRATEGY VI: Client Needs

A. Safe, Effective Care Environment

1. These questions address the nurse’s role in providing and directing care that will ensure an environment that promotes protecting the client, family or significant others and other health care personnel.

2. Content addressed in these questions relates to the nursing role of coordinating and integrating cost-effective care, supervising and/or collaborating with members of the multidisciplinary health care team, and environmental safety.

3. Be alert to safety needs addressed in a question, and remember the importance of hand washing, call bells, bed positioning, the appropriate use of side rails, and standard precautions.

B. Physiological Integrity

1. These questions address the nurse’s role in promoting physical health and well-being in the client by providing care and comfort, reducing client risk potential, and managing the client’s health alterations.

2. Content addressed in these questions relates to basic care and comfort, pharmacological and parenteral therapies, reducing the risk of the development of complications, and managing and providing care to clients with acute, chronic, or life-threatening conditions.

3. Remember that physiological needs are a priority and are addressed first.

4. Use the ABC’s airway, breathing, and circulation; Maslow’s hierarchy of needs theory; and the steps of the nursing process when selecting an option addressing physiological integrity.

C. Psychosocial Integrity

1. These questions address the nurse’s role in providing nursing care that supports and promotes the emotional, mental, and social well-being of the client and significant others.

2. Content addressed in these questions relates to promoting the client’s or significant other’s ability to cope, adapt or problem solve in situations such as illness or stressful events and to providing care to clients with maladaptive behavior or acute or chronic mental illness.

3. In this Client Needs category you may be asked communication-type questions that relate to how you would respond to a client, a client’s family member or significant other, or to other health care team members.

4. Use therapeutic communication techniques to answer communication questions because of their effectiveness in the communication process.

5. Remember to select the answer that focuses on the client’s, client’s family members or significant other’s feelings, concerns, anxieties, or fears.

PRACTICE QUESTION: Communication

A mother says to the nurse. “I am afraid that my child might have another seizure.” Which response by the nurse is most therapeutic?

1. “Why worry about something that you cannot control?”
2. “Most children will never experience a second seizure.”
3. “Tell me what frightens you the most about seizures.”
4. “Acetaminophen (Tylenol) can prevent another seizure from occurring.”

Answer: 3

Test-taking Strategy: Option 3 is the only option that addresses the client’s fears. Option 1 blocks communication because it states that the mother should not worry. Options 2 and 4 are incorrect because the nurse is giving false assurance that a seizure will not reoccur or can be prevented in this child. Remember focus on feelings, concerns, anxieties or fears.

D. Health Promotion and Maintenance

1. These questions address the nurse’s role in providing and directing nursing care that prevents health problems, provides early detection of health problems, and provides and directs care that incorporates knowledge of expected growth and development principles.

2. Content addressed in these questions relates to assisting the client and significant others through the normal stages of growth and development and assisting the client and significant others to develop health practices that promote wellness and to recognize alterations in health care status.

3. Use the teaching/learning theory if the question addresses client education, remembering that client motivation and client readiness to learn is the first priority.

4. Be alert to false response questions that address health promotion and maintenance and client education.

NURSING TEST TAKING STRATEGY V: G. Steps of the Nursing Process - EVALUATION

V: Questions that Require Prioritizing

7. EVALUATION

a. Evaluation questions focus on comparing the actual outcomes of care with the actual outcomes of care with the expected outcomes and focus on how the nurse should monitor or make a judgement concerning a client’s response to therapy or to a nursing action.

b. These questions address evaluating the client’s ability to implement self-care, health care members’ ability to implement care, and the process of communicating and documenting evaluation findings.

c. In an evaluation question, be alert to false response question because they are used frequently in evaluation-type questions, and the question may ask for a client statement that indicates accurate or inaccurate information related to the issue of the question.

PRACTICE QUESTION: The Nursing Process – Evaluation

A client with multiple sclerosis has been taking oxybutynin (Ditropan). The nurse determines the degree of effectiveness of the medication by asking the client about changes in the following:

1. Extent of muscle spasms
2. Level of fatigue
3. Bowel movements
4. Pattern of urination

Answer: 4

Test-Taking Strategy: This is an evaluation question. Note the key words determine the degree of effectiveness. Oxybutynin is antispasmodic used to relieve symptoms of urinary urgency, frequency, nocturia, and incontinence in clients with uninhibited or reflex neurogenic bladder. Recalling that this medication is used to treat bladder dysfunction will direct you to option 4. Remember evaluation is the fifth step of the nursing process.

NURSING TEST TAKING STRATEGY V: G. Steps of the Nursing Process - IMPLEMENTATION

V: Questions that Require Prioritizing

6. IMPLEMENTATION

a. Implementation questions address the process of organizing and managing care, counselling and teaching, providing care to achieve established goals, supervising and coordinating care, and communicating and documenting nursing interventions.

b. This examination is about nursing, so focus on the nursing action rather than on the medical action unless the question is asking you what prescription (medical order) is anticipated.

c. The only client about whom you need to be concerned is the client in the question that you are answering; remember that this client is your only assigned client.

d. Answer the questions as if the situations were textbook and ideal and the nurse had all the time and resources needed and readily available at the client’s bedside.

PRACTICE QUESTION: The Nursing Process – Implementation

A nurse is caring for a client with angina pectoris who begins to experience chest pain. The nurse administers a sublingual nitroglycerin (Nitrostat) tablet sublingually as prescribed, but the pain is unrelieved. The nurse should take which of the following actions next?

1. Contact the physician
2. Call the client’s family.
3. Administer another nitroglycerin tablet.
4. Reposition the client.

Answer: 3

Test-Taking Strategy: Implementation questions address the process of organizing and managing care. This question also requires that you prioritize the nursing actions. Note the key word next. Recalling that the nurse would administer three nitroglycerin tablets 5 minutes apart from each other to relieve chest pain will assist in directing you to option 3. Remember implementation is the fourth step of the nursing process.

NURSING TEST TAKING STRATEGY V: G. Steps of the Nursing Process - PLANNING

V: Questions that Require Prioritizing

5. PLANNING

a. Planning questions require prioritizing nursing diagnosis, determining goals and outcome criteria for goals of care, developing the plan of care, and communicating and documenting the plan of care.

b. Regarding nursing diagnoses, remember that actual client problems rather than potential or at risk client problems will most likely be the priority.
c. Remember that this is a nursing examination and the answer to the question most likely involves something that is included in the nursing care plan, rather than the medical plan.

PRACTICE QUESTION: The Nursing Process – Planning
A nurse develops a plan of care for a client with a cataract. Which nursing diagnosis is the priority?
1. Fear related to lost of eyesight
2. Social isolation related to decrease ability to mobilize in the community.
3. Disturbed Sensory Perception (visual) related to ocular lens opacity.
4. Risk for injury related to decrease vision.
Answer: 3
Test-Taking Strategy: This question relates to planning nursing care and asks you to identify the priority nursing diagnosis. Use Maslow’s hierarchy of needs theory to answer the questions. Remembering that physiological needs are the priority will direct you to option 3. Although Risk for Injury is a potential rather than an actual problem, according to Maslow’s hierarchy of needs theory, safety is the second priority. Fear and Social Isolation are psychosocial needs. Remember planning is the third step of the nursing process.