NUR 111 Introduction to Health Concepts

Correct Answer:

Back channeling.

Explanation:

Back channeling is a therapeutic communication technique where the nurse uses verbal and nonverbal cues such as “all right,” “go on,” or nodding to encourage the patient to continue sharing information. It helps demonstrate active listening, supports patient expression, and ensures the patient feels heard without interrupting their flow of communication.

Why Other Options Are Wrong:

Open-ended questions.

This is incorrect because open-ended questions involve asking broad questions that invite elaboration, such as “Tell me more about how you’ve been feeling.” While helpful in interviews, open-ended questions are not the same as short encouraging cues like “go on.”

Probing.

This option is not correct because probing involves asking follow-up or detailed questions to explore information more deeply, such as “Can you describe the pain more specifically?” Back channeling, in contrast, does not seek new information but encourages the client to continue.

Interview techniques.

While back channeling is indeed a type of interview technique, this option is too broad and vague. The question asks for the specific technique demonstrated by phrases like “all right” or “go on,” which directly identifies back channeling.

Correct Answer:

The goal has no target time.

Explanation:

A proper nursing goal must be specific, measurable, achievable, realistic, and time-bound (SMART). While this goal is specific, measurable, realistic, and relevant, it lacks a timeframe. For example, stating “by the end of the shift” or “within 24 hours” would make it complete.

Why Other Options Are Wrong:

The goal is not realistic.

This is incorrect because reducing pain to ≤3 is a realistic and achievable outcome for most clients.

The goal is written correctly.

This is incorrect because it is missing a target time, which is an essential component of a correctly written nursing goal.

The goal is not measurable.

This is incorrect because the 0–10 pain scale is a measurable and objective tool used to quantify pain levels.

Correct Answer:

Planning

Explanation:

The planning phase of the nursing process involves setting patient-centered goals and expected outcomes. By asking the client what pain goal they have, the nurse collaborates with the patient to establish realistic, individualized objectives. This ensures care is tailored to the patient’s preferences and needs, supporting shared decision-making and effective management of pain.

Why Other Options Are Wrong:

Implementation

This is incorrect because implementation refers to the actual carrying out of interventions designed to achieve established goals. Asking about goals occurs before interventions begin, meaning this step fits into planning, not action.

Evaluation

This option is not correct because evaluation takes place after interventions are performed. In evaluation, the nurse determines whether the goals were met and adjusts the care plan if necessary. Asking about the goal happens before interventions and evaluation.

Assessment

Assessment involves collecting subjective and objective data about the client’s current condition. While pain assessment is part of this phase, asking about the patient’s desired pain goal relates more to goal-setting, which belongs in planning.

Correct Answer:

Modify the nursing interventions.

Explanation:

When a client’s goal is not met, the nurse must evaluate and modify the plan of care to address the client’s needs and concerns. In this case, fear of falling is preventing ambulation, so interventions should be adjusted to build confidence and safety, such as providing assistive devices, supervision, or fall-prevention education. Modifying interventions ensures that the care plan remains individualized, realistic, and effective in meeting the client’s health goals.

Why Other Options Are Wrong:

Notify the primary health-care provider.

This is incorrect because the situation does not yet require physician involvement. The issue stems from the client’s fear, which can be managed through nursing interventions. Notifying the provider may come later if the issue persists despite adjusted nursing strategies.

Consult physical therapy.

This is wrong because while physical therapy could eventually help, the immediate priority is for the nurse to adapt care to address the client’s fear. Consulting physical therapy without first modifying the nursing interventions bypasses the nurse’s role in problem-solving within the care plan.

Write a new nursing diagnosis.

This option is incorrect because the existing diagnosis and problem remain valid—the client is afraid of falling, preventing ambulation. The plan does not need an entirely new diagnosis but rather a modification of interventions to support progress toward the original goal.

Correct Answer:

Client will have intake of at least 1000 mL by the end of shift.

Explanation:

A complete nursing goal must be specific, measurable, achievable, realistic, and time-bound (SMART). “Client will have intake of at least 1000 mL by the end of shift” is measurable, addresses the fluid deficit directly, and sets a realistic timeframe. It provides clear criteria for evaluating whether the goal is met.

Why Other Options Are Wrong:

Client will have moist mucous membranes.

This is not time-bound or easily measurable within one shift. Mucous membrane moisture may take longer to change and is subjective.

Client will verbalize ways to take in more fluid.

This focuses on knowledge and teaching, not actual correction of fluid volume deficit. It does not directly measure fluid balance improvement.

Client will have good skin turgor by the end of the shift.

This is unrealistic, as skin turgor takes time to improve after hydration. It is not an achievable short-term outcome for a single shift.

Correct Answer:

Fluid volume excess related to compromised regulatory system of the heart as evidence by edema in the lower extremities and weight gain.

Decrease cardiac output related to cardiac muscle damage secondary to myocardial infarction as evidence by EKG changes.

Ineffective airway clearance as evidence by decrease O2 saturation and increased respiratory rate.

Risk for constipation related to opioid use.

Explanation:

Fluid volume excess related to compromised regulatory system of the heart as evidence by edema in the lower extremities and weight gain.

This statement is correct because it follows the NANDA format: problem (fluid volume excess), etiology (compromised heart regulation), and defining characteristics (edema and weight gain). It provides a clear cause-and-effect relationship and measurable evidence that supports the diagnosis. The inclusion of observable symptoms such as edema and weight gain ensures that the diagnosis is specific and clinically valid.

Decrease cardiac output related to cardiac muscle damage secondary to myocardial infarction as evidence by EKG changes.

This is correct because it specifies the problem (decreased cardiac output), the underlying cause (cardiac muscle damage from MI), and the evidence (EKG changes). It is written in a structured manner and uses objective findings to support the diagnosis. This ensures that the nurse has identified both the physiological cause and the measurable clinical evidence that validates the diagnosis.

Ineffective airway clearance as evidence by decrease O2 saturation and increased respiratory rate.

This diagnosis is correct because it clearly identifies the problem (ineffective airway clearance), omits the “related to” phrase when the cause is evident, and supports the diagnosis with objective defining characteristics (low oxygen saturation and increased respiratory rate). Both signs can be measured and documented, making the statement clinically accurate and aligned with NANDA guidelines.

Risk for constipation related to opioid use.

This statement is correct because risk diagnoses do not include “as evidenced by” since the problem has not occurred yet. Instead, they identify the risk factor that places the client at risk—in this case, opioid use. The structure is accurate, concise, and reflects the proper NANDA format for risk diagnoses, making it a valid nursing diagnostic statement.

Why Other Options Are Wrong:

Acute Confusion secondary to stroke related to patient is confused.

This is incorrect because it restates the problem (“patient is confused”) instead of identifying actual contributing factors or measurable evidence. A correct statement would be written as “Acute Confusion related to decreased cerebral perfusion secondary to stroke as evidenced by disorientation and difficulty following commands.” The provided option lacks proper structure and does not meet diagnostic statement standards.

Correct Answer:

“Hello, I’m your nursing student and I’ll be helping to take care of you today.”

Explanation:

The best way to establish rapport is by greeting the client, introducing yourself, and clearly identifying your role. This builds trust, sets expectations, and promotes a professional relationship. By stating their name and role, the nursing student communicates respect and readiness to care for the patient.

Why Other Options Are Wrong:

“Hi. If you need anything, either your nurse or I will get it for you.”

This offers assistance but does not include a proper self-introduction or clarify the student’s role, which is essential when first meeting a client.

“You’re lucky, you have students and nurses taking care of you today.”

This is unprofessional and inappropriate. Rapport is built on respect and trust, not casual or dismissive remarks.

“Good morning, is there anything you need right now?”

While polite and helpful, this opening skips self-introduction and role clarification, leaving the client unclear about who the student is.

Correct Answer:

Nursing Interventions Classifications (NIC).

Explanation:

The Nursing Interventions Classification (NIC) system provides a standardized language for nursing interventions. It allows nurses to clearly document, organize, and communicate treatments and actions across healthcare teams. NIC improves consistency, supports evidence-based practice, and ensures that interventions are clearly defined and understood in all clinical settings.

Why Other Options Are Wrong:

Quality and Safety Education for Nurses (QSEN).

QSEN is an educational initiative focused on preparing nurses with the knowledge, skills, and attitudes for quality and safety in healthcare. It is not a standardized communication system.

Clinical Practice Guidelines.

These are evidence-based recommendations for managing specific conditions. They provide direction for care but are not a standardized nursing language system.

Dependent Nursing Interventions.

These require a provider’s order and are part of nursing care, but they do not represent a communication framework or classification system.

Correct Answer:

Inductive reasoning.

Explanation:

Inductive reasoning is a clinical decision-making approach where nurses analyze specific pieces of patient data and then draw inferences to reach a conclusion about the patient’s condition. It allows the nurse to move from particular observations, such as symptoms and assessment findings, to a broader understanding of the patient’s status. This process supports accurate clinical judgments based on evidence.

Why Other Options Are Wrong:

Intuition.

This is based on a nurse’s instincts or past experiences rather than a structured review of specific patient data. While intuition can be valuable, it is not the same as systematically drawing inferences from data.

Clinical judgement model.

This is a comprehensive framework involving noticing, interpreting, responding, and reflecting. It goes beyond reviewing specific data and inference-making, making it broader than the concept asked in the question.

Scientific Method.

This refers to a structured process of hypothesis testing in research, not the immediate clinical reasoning process nurses use at the bedside. It is more formal and not typically applied in everyday patient assessment.