Chapter 17 & 18
The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
"Begin with the highest priority diagnoses, then select appropriate interventions."
A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.)
-Assess condition of skin before making the call -Explain the patient's response emotionally to the repeated leaking of stool -Describe the type of bag being used and how long it lasts before leaking
Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
-Impaired Skin Integrity related to physical immobility -Nausea related to gastric distention
A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply.)
-Maintaining intravenous (IV) infusion at 100 mL/hr -Consulting with dietitian on initial foods to offer patient
Which of the following nursing diagnoses is stated correctly? (Select all that apply.)
-Sleep Deprivation related to sustained noisy environment -Ineffective Protection related to inadequate nutrition
A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. What are the steps for making a nursing diagnosis in the correct order, beginning with the first step? 1. Considers context of patient s health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. Clusters clinical cues that form a pattern 4. Chooses diagnostic label
2,3,4,1
Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?
Acute pain
A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.)
Data collection. Data interpretation
The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?
Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed
A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?
Dependent
A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?
Diagnostic reasoning
A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement?
Identifying the medical diagnosis instead of the patient's response to the diagnosis.
Which action indicates the nurse is using a PICOT question to improve care for a patient?
Implements interventions based on scientific research
The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?
Interdependent
A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? ( Select all that apply.)
Rank all the patient's nursing diagnoses in order of priority. Consider time as an influencing factor. Utilize critical thinking
A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first?
Reconnect the drainage tubing
In which of the following examples are nurses making diagnostic errors? (Select all that apply.)
The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.
A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?
The patient will feed self at all mealtimes today without reports of shortness of breath.
The following statements are on a patient's nursing care plan. Which statement will the nurse use as an outcome for a goal of care?
The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.
The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n):
problem-focused nursing diagnosis
