Nursing process prep u
A nursing diagnosis should come from...
A cluster of significant data
A nurse writes the following nursing diagnosis for a patient with Alzheimer's: Disturbed Thought Processes related to Alzheimer's disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement? a. disturbed thought processes b. related to c. Alzheimer's disease d. incoherent language
a
The nurse has been working with a patient for several days during the patient's recovery in hospital from a femoral head fracture. How should a nurse best evaluate whether patient education regarding falls prevention in the home has been effective? a. "What changes will you make around your house to reduce the chance of future falls?" b. "Do you have any questions about the fall prevention measures that we've talked about?" c. "In light of what we've talked about, why is it important that you remove the throw rugs in your house?" d. "Do you think that the safety measures I taught you are clear and realistic?"
a
The purpose of establishing a nursing diagnosis is to a.Describe a functional health problem b.. Collaborate with the physician c.. Identify medical problems d.. Meet accreditation criteria
a
After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? a.Wellness b.Actual c.Risk d.Possible
b
The nurse performs a comprehensive assessment of a newly admitted client. What is the primary purpose of this admission assessment? a. Initiate a therapeutic relationship b. Identify baseline data c. Provide orientation to the facility d. Determine risk factors
b
On admission, a client is completely immobilized by an acute exacerbation of multiple sclerosis. Two days later, the client cries frequently and refuses to see family members. The nurse formulates a nursing diagnosis of Hopelessness. To address this diagnosis, the nurse should include which intervention in the care plan? a. Obtaining an order for sedation b. Limiting visitors to 15 minutes per day c. Encouraging the client to verbalize feelings d. Reinforcing the client's responsibility to the family
c
The nurse formulates the following client outcome: "Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7." Which error has the nurse made? a. Expressed the client outcomes as a nursing intervention b. Wrote vague outcomes that will confuse other nurses c. Included more than one client behavior in the outcome d. Used verbs that are not observable and measurable
c
The client's expected outcome is "The client will maintain skin integrity by discharge." Which of the following measures is best in evaluating the outcome? a. The client's ability to reposition self in bed. b. Pressure-relieving mattress on the bed. c. Percent intake of a diet high in protein. d. Condition of the skin over bony prominences.
d
