Fundamentals ch. 5&10

Risk for impaired skin integrity related to physical immobilization is the only appropriately written patient problem. All other options are not listed as NANDA-I approved patient problems.

A nurse is formulating a patient problem. What is an example of an appropriately written patient problem?

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. The patient is jaundiced is an example of objective data. All other options are examples of subjective data.

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of nausea is an example of subjective data. All other options are examples of objective data.

During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

To protect infants and children from burns, turn the pot handles on stoves away from the child's reach

What important safety precaution should the home health nurse teach parents in order to prevent burns to small children?

Secondary sources include family members.

What is classified as information provided by the family when a patient is unable to provide data during assessment?

Impaired skin integrity is the only example of a patient problem; all other options are examples of medical diagnoses.

Which is an example of a patient problem?

The two primary methods of collecting data are interviewing and physical examination.

what are the two primary methods used to collect data?

Implementation is the nurse carrying out nursing orders to promote outcome achievement.

what documentation reflects implementation?

A useful framework to guide prioritization is Maslow's hierarchy of needs.

what framework does the establishment of priorities of care during the planning phase of the nursing process often use?

A head-to-toe format provides a systematic approach.

what organized approach might the nurse use when performing a complete physical examination?

Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan.

what type of assessment is performed continuously throughout nurse-patient contact?

The RN is responsible for analyzing and interpreting data.

who is the person responsible for analyzing and interpreting date to arrive at the patient problem?

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Pacing back and forth while chanting is an example of objective data. All other options are examples of subjective data.

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Shortness of breath on exertion is an example of objective data. All other options are examples of subjective data.

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

Plans are more effective when the patient is involved in the process. The care plan is not limited in terms of the number of interventions, nor do they have to be easy. The patient problems are not evaluated; the patient's progress toward the outcome is.

What is an important consideration when developing the care plan?

The patient problem is the basis for developing nursing interventions.

What is the basis for designing and selecting nursing interventions to meet patient needs?

Initially, an order is necessary that specifies the type of SRD and the duration of its application.

What must the nurse do before applying a safety reminder device (SRD)?

Objective data are observable and measurable by people other than the patient.

What objective data should the nurse include after a patient assessment?

In the event of a mercury spill, interior doors should be closed and outside windows should be opened. The spill should not be vacuumed.

What should a nurse do when encountering a mercury spill?

Filling the cup half full promotes safety and does not change the flavor of the beverage, nor does it demean the patient as would making him or her wear a bib or apron.

What should the nurse do when offering a cup of hot coffee to a frail, older adult patient?

The majority of patient falls occur during transfer.

What skills should health care workers frequently attend in-services about to ensure that staff has competent skills and risk for falls can be decreased?

Electric fires require type C fire extinguishers.

What type of fire extinguisher should the nurse use when the oxygen concentrator machine malfunctions and causes an electric fire?

During the planning phase, the nurse connects nursing interventions to nursing orders.

When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process?

Pneumonia is the only example of a medical diagnosis; all other options are examples of patient problems.

Which is an example of a medical diagnosis?

A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses.

All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment?