Evolve Chapter 5 Fundamentals Core

For Medicare, a reassessment of a patient in a long-term care facility must be done every: 30 days. 60 days. 90 days. 120 days.

90 days *For Medicare patients, a reassessment by a registered nurse is necessary every 90 days.

To conduct a physical examination of a patient, which examination technique is used? Percussion of an area Weighing of a patient History taking Communication

Percussion of an area *Inspection, auscultation, palpation, and percussion are examination techniques. Weighing a patient, history taking, and communication are not considered examination techniques.

What is the third step of the nursing process? Planning Evaluation Implementation Nursing diagnosis

Planning *Planning is the third step of the nursing process. Evaluation is the last step of the nursing process. Implementation occurs after planning. Nursing diagnosis is the second step of the nursing process.

Which statement is true regarding nursing diagnoses? A nursing diagnosis describes a health problem amenable to intervention. LPNs/LVNs formulate nursing diagnoses. Medical diagnosis is included in the nursing diagnosis. North American Nursing Diagnosis Association (NANDA) revises the diagnostic labels every 5 years.

A nursing diagnosis describes a health problem amenable to intervention *A nursing diagnosis statement indicates the patient's actual health status or the risk of a problem developing, the causative or related factors, and specific defining characteristics (signs and symptoms). The health problem described by nursing diagnosis is amenable to intervention. RNs formulate nursing diagnoses. The medical diagnosis is never included in the construction of a nursing diagnosis. NANDA revises the diagnostic

Which data collection method uses functional patterns to represent the interaction between the patient and the environment? Focused assessment Maslow's hierarchy of needs Gordon's health patterns Scientific method

Gordon's health patterns *Gordon formulated a structural format to obtain a comprehensive database based on 11 functional health patterns. Review of the patterns may indicate patient problems. Focused assessment is concerned with only one specific problem. Maslow's hierarchy of needs does not use functional patterns. Scientific method does not use functional patterns.

Which is a long-term goal for a patient? Pain management Stroke rehabilitation Adequate fluid intake Treatment of a urinary tract infection (UTI)

Stroke rehabilitation *Long-term goals often relate to rehabilitation. Stroke rehabilitation will require more time than short-term goals, which are achievable within 7 to 10 days. Pain management, adequate fluid intake, and treatment of UTI are considered short-term goals.

Which is an example of objective data? Pain Temperature Headache Lightheadedness

Temperature *Information obtained through the senses and hands-on physical examinations are objective data. Vital signs, including temperatures, are objective data. Pain, headache, and lightheadedness are considered subjective data.

Which stages are included in an interview? (Select all that apply.) Opening Body Discussion Closing

The opening, the body, and the closing are stages in an interview. Discussion is not a stage in an interview.

One of the highest priorities of nursing care is: adequate nutrition. maintaining skin integrity. pain control. airway management.

airway management *In prioritizing care, physiologic needs for basic survival take precedence. Airway management always comes first. Without an adequate airway, a patient will die. Nutrition, maintaining skin integrity, and pain control are lower priorities of care than airway management.

_______ are pieces of data or information that influence decisions.

cues *Clients' data are analyzed for cues that indicate deviations from the norm. Cues are pieces of data or information that influence decisions.