nursing process
The physician has ordered cimetidine for a client with gastric ulcers, and the nurse administers the first dose. The nurse's actions are noted in the medical record. This notation is an example of which aspect of implementing the plan of care? documentation intervention monitoring assessment
Correct response: documentation Explanation: An important element of implementation is documentation. By law, nurses must document all nursing actions, observations, and client responses in a permanent record.
A father runs into the emergency room with his 18-month-old son in his arms. The father screams, "Help, he is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis? no priority low priority medium priority high priority
Correct response: high priority Explanation: To develop a prioritized list of nursing diagnoses, the nurse needs guidelines for ranking diagnoses as high, medium, or low priority. High-priority diagnoses pose the greatest threat to the patient's well-being (in this case, decreased oxygenation is the greatest threat to well-being and life).
A nurse using critical thinking interprets data and determines appropriate interventions. What factor will affect the nurse's ability to employ critical thinking with data interpretation? the nurse's gender the nurse's personal biases the date of the client's admission the client's admission diagnosis
Correct response: the nurse's personal biases Explanation: Nurses using critical thinking will consider the possibility of personal bias when interpreting data. The other options such as the nurse's gender and the client's admission date and diagnosis are not appropriate considerations with using critical thinking.
A client presents to the acute care facility with several signs and symptoms. How will the nurse determine and prioritize the client's healthcare needs? using a systematic method to plan and implement care to reach desired outcomes contacting the physician before performing any tasks consulting with other nurses to determine the first step of care reading the client's records and doing research on the client's conditions before deciding on a course of action
Correct response: using a systematic method to plan and implement care to reach desired outcomes Explanation: Clients present with multiple healthcare needs that the caregiver must approach in an organized, systematic manner to provide efficient and effective care. The nursing process for making clinical decisions grew from problem-solving techniques and the scientific process.
A client is scheduled for surgery for an abdominal hysterectomy and during the preoperative assessment the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? Evaluate the need for antibiotics Resolve the client's anxiety Provide preoperative education Prepare the client for surgery
A client is scheduled for surgery for an abdominal hysterectomy and during the preoperative assessment the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? Evaluate the need for antibiotics Resolve the client's anxiety Provide preoperative education Prepare the client for surgery
The nursing process is integral to the accurate and complete delivery of nursing care. Which of the following activities represent aspects of the nursing process? Select all that apply. Taking a client's health history Selecting interventions to cure the client's medical diagnoses Comparing client outcomes against planned goals Ordering an antidiabetic agent for a client newly diagnosed with diabetes Prioritizing activities to improve client comfort
Taking a client's health history Comparing client outcomes against planned goals Prioritizing activities to improve client comfort The nursing process is a deliberate problem-solving approach for meeting a client's health care and nursing needs. The components of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Within each component are nursing activities to assist clients. Examples include taking a health history and performing a physical assessment, planning client-centered goals, implementing interventions within the RN scope of practice, prioritizing activities, and evaluating actual outcomes against expected goals. A nurse would not order medications. The nurse would not direct the focus of interventions toward curing the medical problems; rather, her or she would focus the interventions on providing care to address the client's nursing diagnoses.
The nurse is revising a client's care plan. When determining goals for the client, what is the process for the expected outcomes? Select all that apply. The outcomes are directed to the nurse. The outcomes evaluate medical care. The outcomes are derived from nursing diagnoses. The outcomes are measurable goals. The outcomes include a time estimate for the achievement of short- and long-term outcomes.
The outcomes are derived from nursing diagnoses. The outcomes are measurable goals. The outcomes include a time estimate for the achievement of short- and long-term When writing expected outcomes, the nurse should relate them directly to the nursing diagnoses and include the appropriate time frame for completion. Goals are clear, specific, and measurable statements. Outcomes are client-centered, not nurse centered, and evaluate nursing interventions.
The nurse is revising a client's care plan. When determining goals for the client, what is the process for the expected outcomes? Select all that apply. The outcomes are directed to the nurse. The outcomes evaluate medical care. The outcomes are derived from nursing diagnoses. The outcomes are measurable goals. The outcomes include a time estimate for the achievement of short- and long-term outcomes.
The outcomes are derived from nursing diagnoses. The outcomes are measurable goals. The outcomes include a time estimate for the achievement of short- and long-term outcomes. When writing expected outcomes, the nurse should relate them directly to the nursing diagnoses and include the appropriate time frame for completion. Goals are clear, specific, and measurable statements. Outcomes are client-centered, not nurse centered, and evaluate nursing interventions.
A nurse is formulating a nursing diagnosis for a patient with a respiratory disease. Which of the following would be correct? "needs nasal oxygen to improve breathing" "cough related to ineffective airway clearance" "ineffective airway clearance related to thick mucus" "refuses to cough and expectorate thick mucus"
Correct response: "ineffective airway clearance related to thick mucus" Explanation: It is important to use guidelines to formulate correctly written nursing diagnoses. The nurse would not use patient needs, put defining characteristics before the diagnoses, or judge the willingness of the patient to cough.
The nurse continues to work the care plan for a client admitted with hepatic cirrhosis. Even though the client seems uninterested in learning about the disease process, why would the nurse continue to instruct him on proper diet, exercise, alcohol avoidance, etc.? Actively involved clients are more committed to achieving plan outcomes. The nurse manager's priority is for all clients to receive continual patient education The more the client hears the information the less likely the client is to repeat mistakes. None of the options is correct.
Correct response: Actively involved clients are more committed to achieving plan outcomes. Explanation: Respecting clients' rights to participate in their healthcare is an important ethical principle. Actively involved clients are more committed to carrying out the plan and achieving the outcomes.
A nurse has developed a plan of care with nursing interventions designed to meet specific patient outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation? Continue to follow the written plan of care. Make recommendations for revising the plan of care. Ask another healthcare professional to design a plan of care. State "goal will be met at a later date."
Correct response: Make recommendations for revising the plan of care. Explanation: Patient outcomes are meaningless unless the nurse evaluates the patient's progress toward their achievement. If the plan is not achieved (not met), recommendations for revising the plan of care are included in the evaluative statement.
The nurse is caring for a group of clients. What priority nursing intervention illustrates planned nursing care prioritized according to Maslow's hierarchy of needs? Administer pain medication to a client before transportation to physical therapy for crutch-walking exercises. Discourage a terminally ill client from participating in a plan of care, to minimize fears about death. Help a client walk to the shower because the shower area is vacant at this time. Interrupt a family's visit with client with depression to assess blood pressure measurement.
Correct response: Administer pain medication to a client before transportation to physical therapy for crutch-walking exercises. Explanation: Assigning priorities to nursing diagnoses and collaborative problems is a joint effort by the nurse and the client or family members. Any disagreement about priorities is resolved in a way that is mutually acceptable. Consideration must be given to the urgency of the problems, with the most critical problems receiving the highest priority. Maslow's hierarchy of needs provides one framework for prioritizing problems, with importance being given first to physical needs like pain medication needs; once those basic needs are met, higher-level needs like client participation in care or taking advantage of an empty shower area can be addressed. The disruption of a family visit is not necessary unless the client is unstable. Reference: Donnelly-Moreno, L.A., Timby's Introductory Medical-Surgical Nursing, 13th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 3: The Nursing Process, STEPS OF THE NURSING PROCESS, Planning, p. 23. Chapter 3: The Nursing Process - Page 23
While caring for a client with a deep vein thrombosis of the leg, the nurse monitors for collaborative problems. Which action will the nurse implement while treating collaborative problems for this client? Consider discharge placement. Monitor intake and output every 4 hours. Order a heparin bolus. Assess the respiratory status every 4 hours.
Correct response: Assess the respiratory status every 4 hours. Explanation: Collaborative problems are physiologic complications for which nurses monitor. By assessing the client's respiratory status, the nurse is monitoring for the complication of a pulmonary embolism.
The nurse assesses a radial pulse rate of 48 beats per minute (bpm). Using critical thinking, what will be the best action for the nurse to take? Assess blood pressure with the client lying supine. Ask a fellow nurse to double-check your pulse rate assessment. Call the health care provider to get orders. Check the client's previous pulse rates to validate the findings.
Correct response: Check the client's previous pulse rates to validate the findings. Explanation: Critical thinkers validate information to make sure that it is accurate or makes sense. In this case, the nurse will review previous rates to see if this finding is a deviation from the client's usual rate. Assessing the client's blood pressure is collecting more data, and this information would not help confirm whether the client ordinarily has a low pulse rate. Asking another nurse for help is fine, but is not an example of using critical thinking. The health care provider will need more client data.
When the nurse prepares to discharge a client, to evaluate the effectiveness of the nursing care, the nurse should determine whether the Physician orders have been completed Client's goals have been achieved Critical pathways are completed Documentation is thorough
Correct response: Client's goals have been achieved Explanation: Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals based on the client's behavioral responses. This phase involves a thorough, systematic review of the effectiveness of nursing interventions and a determination of client goal achievement.
When the nurse prepares to discharge a client, to evaluate the effectiveness of the nursing care, the nurse should determine whether the Physician orders have been completed Client's goals have been achieved Critical pathways are completed Documentation is thorough
Correct response: Client's goals have been achieved Explanation: Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals based on the client's behavioral responses. This phase involves a thorough, systematic review of the effectiveness of nursing interventions and a determination of client goal achievement. Reference: Donnelly-Moreno, L.A., Timby's Introductory Medical-Surgical Nursing, 13th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 3: The Nursing Process, STEPS OF THE NURSING PROCESS, Evaluation, p. 25. Chapter 3: The Nursing Process - Page 25
Analyzing information for patterns, maintaining a flexible attitude, and making decisions reflecting creativity are all what type of components necessary for nurses? Critical thinking Rationalism Moral thinking Utilitarianism
Correct response: Critical thinking Explanation: Critical thinking requires going beyond basic problem-solving and results in comprehensive plans of care.
A patient that has had a stroke is not able to eat without maximum assistance and has a nursing diagnosis of "Imbalanced nutrition, less than body requirements, related to inability to feed self." What would be an immediate nursing outcome for the patient to achieve? Acquire competence in managing cookware designed for handicapped people. Assume independent responsibility for meeting self-nutrition needs. Learn about food products that require minimal preparation yet meet individual needs for a balanced diet. Master the use of special eating utensils to feed self.
Correct response: Master the use of special eating utensils to feed self. Explanation: Immediate goals are those that can be attained within a short period. Intermediate and long-term goals require a longer time to be achieved and usually involve preventing complications and other health problems and promoting self-care and rehabilitation.
Which source of information helps the nurse formulate nursing diagnoses for a specific client? Research articles Essential assessment data Outcome criteria Admission criteria
Correct response: Essential assessment data Explanation: In the diagnostic phase of the nursing process, the client's nursing problems are defined through analysis of client data. Establishing a plan comes after collecting and analyzing data, evaluating a plan is the last step of the nursing process, and assigning a positive value to each consequence is not done.
A client reports postoperative pain near the incision site on his abdomen. He describes the pain as constantly burning and rates it at an 8/10 using the pain scale. The nurse administers morphine sulfate 2 mg IVP as ordered. Ten minutes later the nurse documents that the client now rates his pain at a 3/10 using the pain scale. The nurse's documentation is an example of which part of the nursing process? Analysis Evaluation Assessment Data collection
Correct response: Evaluation Explanation: Evaluation, the final step of the nursing process, allows the nurse to determine the client's response to the nursing interventions and the extent to which the objectives have been achieved. The other answers are incorrect because they are not the correct phase of the nursing process.
Which type of nursing diagnosis has a goal to increase well-being and enhance specific health behaviors? Health promotion Risk Syndrome Problem-focused
Correct response: Health promotion Explanation: Health promotion nursing diagnoses look for ways to enhance health. Risk nursing diagnoses identify potential problems and use the stem risk for, as in Risk for Impaired Skin Integrity related to inactivity. Syndrome diagnoses are used when the diagnosis is associated with a cluster of other diagnoses. Problem-focused nursing diagnoses identify existing problems.
While reviewing the chart of a client who was recently admitted, the nurse will use the nursing process to set up a plan of care. Order the activities the nurse will do in the most likely sequence from 1 to 5. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Inquire about the reason for the admission. 2Choose the nursing diagnosis of Acute Pain. 3Confer with the client about the desire for pain control. 4Administer the prescribed 4 mg of IV push morphine. 5Re-assess the pain level.
Correct response: Inquire about the reason for the admission. Choose the nursing diagnosis of Acute Pain. Confer with the client about the desire for pain control. Administer the prescribed 4 mg of IV push morphine. Re-assess the pain level. Explanation: The nursing process is a deliberate problem-solving approach for meeting client health care and nursing needs. The common steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation. The nurse will obtain the health history by inquiring about the chief complaint, identify a nursing diagnosis, assist the client to plan a goal, provide treatment, and re-assess the problem.
The registered nurse (RN) is responsible for delegating patient care responsibilities to licensed practical nurses (LPNs) as well as ancillary personnel. What would be the most appropriate task to delegate to a nursing assistant? Assessing the degree of lower leg edema in a patient on bed rest Obtaining vital signs for a patient that has been hospitalized for 3 days Measuring the circumference of a patient's calf for edema Recording the size and appearance of a decubitus ulcer
Correct response: Obtaining vital signs for a patient that has been hospitalized for 3 days Explanation: Implementation includes direct or indirect execution of the planned interventions. It is focused on resolving the patient's nursing diagnoses and collaborative problems and achieving expected outcomes, thus meeting the patient's health needs.
When a nurse notices the client is in pain and needs to learn to walk on crutches which outcome is the priority? Crutch walking Safe walking Capillary refill Pain management
Correct response: Pain management Explanation: In this scenario pain management is the priority. In outcome identification activities performed include establishing priorities.
The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs? Physiologic Safety Love and belonging Self-actualization
Correct response: Physiologic Explanation: Because basic human needs must be met before a person can focus on higher-level needs, patient needs may be prioritized according to Maslow's hierarchy. Physiologic needs, including the need for oxygen, are the most basic and have the highest priority.
What activity is carried out during the implementing step of the nursing process? Assessments are made to identify human responses to health problems. Mutual goals are established and desired patient outcomes are determined. Planned nursing actions (interventions) are carried out. Desired outcomes are evaluated and, if necessary, the plan is modified.
Correct response: Planned nursing actions (interventions) are carried out. Explanation: Reference: Donnelly-Moreno, L.A., Timby's Introductory Medical-Surgical Nursing, 13th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 3: The Nursing Process, STEPS OF THE NURSING PROCESS, Implementation, p. 25. Chapter 3: The Nursing Process - Page 25
The nurse gathers data for a client who has dehydration and formulates a nursing diagnosis of Fluid Volume Deficit related to diarrhea and vomiting as evidenced by poor skin turgor, lethargy, and altered fluid and electrolyte balance. What type of nursing diagnosis is identified with this client? Risk nursing diagnosis Syndrome nursing diagnosis Health promotion nursing diagnosis Problem-focused nursing diagnosis
Correct response: Problem-focused nursing diagnosis Explanation: Problem-focused nursing diagnoses identify existing problems, such as Urinary Retention or Anxiety. Health promotion nursing diagnoses reflect clinical judgment of a client's motivation and behavior to increase well-being and enhance health-seeking behaviors. Syndrome nursing diagnoses describe diagnoses that occur as a group and are best addressed as a group with collective interventions. Risk nursing diagnoses identify potential problems and use the stem risk for, as in Risk for Impaired Skin Integrity related to inactivity.
A 59 year-old client who is status-post cerebrovascular accident with left-sided hemiparesis is making adequate progress. Despite this progress, the client's family insists on establishing an outcome which states the client will "walk one mile without assistance in the next month." As a member of the care team, the nurse should strongly encourage the family to adjust this outcome because it: is not realistic. is not measurable. was not developed with input from all members of the care team. does not include a time estimate for achievement.
Correct response: is not realistic. Explanation: Defining expected outcomes is an important part of the care planning process. The nurse includes the client and family in establishing outcomes. Outcomes are specific and realistic, so the client can attain them and not become frustrated.
A client is scheduled for surgery for an abdominal hysterectomy and during the preoperative assessment the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? Evaluate the need for antibiotics Resolve the client's anxiety Provide preoperative education Prepare the client for surgery
Correct response: Resolve the client's anxiety Explanation: A priority is something that takes precedence in position, deemed the most important among several items. The client's preparation for surgery is important but to have a successful outcome the nurse must address the psychosocial issues related to anxiety.
x A client is scheduled for surgery for an abdominal hysterectomy and during the preoperative assessment the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? Evaluate the need for antibiotics Resolve the client's anxiety Provide preoperative education Prepare the client for surgery
Correct response: Resolve the client's anxiety Explanation: A priority is something that takes precedence in position, deemed the most important among several items. The client's preparation for surgery is important but to have a successful outcome the nurse must address the psychosocial issues related to anxiety.
Which of the following identify a diagnosis associated with a cluster of other diagnoses? Risk nursing diagnoses Problem-focused nursing diagnoses Syndrome diagnoses Health promotion nursing diagnoses
Correct response: Syndrome diagnoses Explanation: Syndrome diagnoses identify a diagnosis associated with a cluster of other diagnoses, such as Disuse Syndrome. Risk nursing diagnoses identify potential problems and use the stem risk for, as in Risk for Impaired Skin Integrity related to inactivity. Health promotion nursing diagnoses reflect clinical judgment of a client's motivation and behavior to increase well-being and enhance health-seeking behaviors. Problem-focused nursing diagnoses identify existing problems.
A newly admitted long-term care client refuses to attend afternoon group activities or social events offered by the facility. According to Maslow's theories on human needs, what is the reason the client refuses to participate in activities? The client needs to increase feelings of positive self-esteem. The client eats the meals served in the room. The client likes to go to have a nap in afternoon and go to bed early in the evening. The client is adjusting to sharing a bathroom and feels in control with bowel elimination.
Correct response: The client likes to go to have a nap in afternoon and go to bed early in the evening. Explanation: According to Maslow, the client would need to be sure that basic physiologic and safety and security needs were being met before becoming interested in meeting love and belonging (social) needs. The client needs to have physical needs met like food, sleep, and bowel elimination before requiring increased self-esteem through social activities.
A client has a nursing diagnosis of "Feeding self-care deficit related to right-sided weakness. Which of the following would be the most appropriate expected outcome for this client? The client will demonstrate an interest in eating during the evening snack. The client will demonstrate an ability to feed himself with a spoon at the morning meal. The client will have a staff member open all packages prior to all meals. The client will not lose any weight throughout the hospital stay.
Correct response: The client will demonstrate an ability to feed himself with a spoon at the morning meal. Explanation: Outcomes are expressed in terms of client behavior and have a time period in which they are to be achieved. The outcome is associated with the nursing diagnosis. In this case, the diagnosis reflects a self-feeding problem caused by weakness. Therefore, being able to feed oneself would be a client behavior the nurse would expect to see achieved.
Which of the following best summarizes the evaluating step of the nursing process? The nurse completes a health assessment to establish a database. The patient and family have met healthcare goals and no longer need care. The nurse and patient identify nursing diagnoses and appropriate interventions. The nurse and patient measure achievement of planned outcomes of care.
Correct response: The nurse and patient measure achievement of planned outcomes of care. Explanation: In evaluating, which is the fifth step of the nursing process, the nurse and patient together measure how well the patient has achieved the outcomes specified in the plan of care.
A client just returned to the unit following abdominal surgery and is in significant pain. Understanding the nursing process, the nurse is aware that assessment will be performed on the client how many times? as often as needed once upon arrival, and one hour later once upon arrival twice per shift
Correct response: as often as needed Explanation: Not only is assessment the first step in the nursing process, it is an important recurring nursing activity that continues as long as a need for healthcare exists. During assessment, the nurse methodically obtains data about the client's health, illness, and change in condition. Reference: Donnelly-Moreno, L.A., Timby's Introductory Medical-Surgical Nursing, 13th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 3: The Nursing Process, STEPS OF THE NURSING PROCESS, Assessment, p. 22. Chapter 3: The Nursing Process - Page 22
Prioritizing client care is an ongoing process within the art of nursing. Abraham Maslow proposed five levels of need and grouped them according to significance. Which client need is of primary importance? breathing easily being safe from falling liking one's roommate being able to keep up with current events while ill
Correct response: breathing easily Explanation: The first-level needs, sometimes called baseline survival needs, have the highest priority. These activities, such as eating, breathing, and drinking, sustain life. Maslow believed humans could not or would not seek to fulfill higher level needs until basic physiologic needs were met. Safety and security are a secondary need, not primary. Needs related to getting along with others are important, but they are not primary needs. Needs related to feeling connected to the larger society are important, but they are not primary needs. Reference: Donnelly-Moreno, L.A., Timby's Introductory Medical-Surgical Nursing, 13th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 3: The Nursing Process, STEPS OF THE NURSING PROCESS, Planning, p. 23. Chapter 3: The Nursing Process - Page 23
How is assessment defined as part of the nursing process? careful observation and evaluation of a client's health status identification and definition of the client's health problem(s) step-by-step planning of client care carrying out the steps in the written plan of care
Correct response: careful observation and evaluation of a client's health status Explanation: During assessment, the nurse methodically obtains data about the client's health and illness. He or she collects information to determine abnormal function and risk factors that contribute to health problems as well as client strengths. The other options define nursing diagnosis, planning, and implementation.
Based on an established plan of care, a nurse turns a patient every 2 hours. What part of the nursing process is the nurse using? assessing planning implementing evaluating
Correct response: implementing Explanation: During the implementing step of the nursing process, the nurse carries out interventions that were developed during the planning step.
Which of the following group of terms best defines assessing in the nursing process? problem focused, time lapsed, emergency based design a plan of care, implement nursing interventions collection, validation, communication of patient data nurse focused, establishing nursing goals
Correct response: collection, validation, communication of patient data Explanation: Assessing is the systematic and continuous collection, validation, and communication of patient data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem focused, time lapsed, and emergency based describe types of assessments. Assessments are nurse focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are.
An ER nurse must quickly assess two clients who were in a car accident and determine whose needs take priority. In this situation, critical thinking allows the nurse to: consider all factors, interpret the information, and make decisions relevant to each client's care. minimize the time spent with each client, so the overall operations of the ER will be more efficient. communicate each client's status more efficiently to the attending physician. delegate tasks to other ER staff, thereby freeing up more time to care for clients presenting with true emergencies.
Correct response: consider all factors, interpret the information, and make decisions relevant to each client's care. Explanation: Nurses use critical thinking skills in all practice settings. Nurses continually assess their clients' needs and frequently confront situations that require multiple interventions. Developing good critical thinking skills will make nurses more efficient and effective at resolving these situations. Reference: Donnelly-Moreno, L.A., Timby's Introductory Medical-Surgical Nursing, 13th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 3: The Nursing Process, The Nursing Process and Clinical Reasoning/Critical Thinking, p. 25. Chapter 3: The Nursing Process - Page 25
The nurse is developing a client's care plan. What activity best exemplifies the assessment phase of the nursing process? assist with ambulation give a complete bed bath determines the client has a pulse rate of 88 bpm check blood pressure daily
Correct response: determines the client has a pulse rate of 88 bpm Explanation: The assessment phase of the nursing process includes a health history and physical examination. The pulse rate is obtained during a physical assessment. The remaining options are not data obtained during the assessment phase, but steps in the implementation phase of the nursing process.
Which type of nursing diagnosis is a clinical judgment of a client's motivation and behavior to increase his or her well-being? health promotion risk syndrome actual
Correct response: health promotion Explanation: The health promotion diagnosis is a judgment of a client's motivation and behavior to increase well-being and enhance health-seeking behaviors. The risk diagnosis identifies potential problems for which the client is at risk. The syndrome diagnosis describes specific diagnoses that occur as a group. The actual diagnosis identifies an existing problem such as Urinary Retention or Acute Anxiety.
A home health nurse reviews the nursing care with the patient and family and then mutually discusses the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating? diagnosing planning implementing evaluating
Correct response: planning Explanation: During the planning step, the nurse identifies expected outcomes of the plan of care. The plan of care should be holistic and individualized, specify desired patient goals and related outcomes, and identify the nursing interventions most likely to meet those expected outcomes.
The nurse is developing a care plan. At which step of the nursing process will the nurse order the primary interventions to achieve a goal? evaluation planning nursing assessment collaborative problems
Correct response: planning Explanation: Nurses will add interventions during the planning stage of the nursing process. Assessment data are gathered through the health history and the physical assessment. Evaluation, the final step of the nursing process, allows the nurse to determine the patient's response to the nursing interventions and the extent to which the objectives have been achieved. Collaborative problems pertain to potential problems or complications that are medical in origin and require collaborative interventions with the health care provider and other members of the health care team.
Which type of nursing diagnosis identifies potential problems that may arise due to the client's disease, condition, or situation? risk actual health promotion syndrome
Correct response: risk Explanation: Risk nursing diagnoses identify potential problems and use the stem "risk for" as in Risk for Impaired Skin IntegrityAltered Skin Integrity Risk related to inactivity. The actual diagnosis identifies an existing problem such as Urinary Retention or Acute Anxiety. The health promotion diagnosis is a judgment of a client's motivation and behavior to increase well-being. The syndrome diagnosis describes specific diagnoses that occur as a group.
A new client in a longterm care facility refuses to attend group activities or social events offered by the facility's social director. Which level of Maslow's hierarchy is addressed by social events? third second fifth fourth
Correct response: third Explanation: Social events address love and belonging needs which is the third level of Maslow's hierarchy.
A longterm care facility's newest client refuses to attend group activities or social events offered by the facility. Which level of Maslow's hierarchy do social events address? third: love and belonging needs second: safety and security needs fifth: self-actualization needs fourth: esteem and self-esteem needs
Correct response: third: love and belonging needs Explanation: Group activities and social events address love and belonging needs, which is the third level of Maslow's hierarchy.
A patient who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? to implement evidence-based practice to ensure the order follows hospital policy to be sure interventions are individualized to be sure the intervention is safe
Correct response: to be sure the intervention is safe Explanation: Nurses reassess the patient and review the plan of care before initiating any nursing intervention to make sure that the plan of care is still responsive to the patient's needs and is safe for the particular patient. In this case, the nurse would not give oral fluids to an unconscious patient.
What is the primary purpose of the planning step of the nursing process? to collect and analyze data to establish a database to interpret and analyze data to identify health problems to write appropriate patient-centered nursing diagnoses to design a plan of care for and with the patient
Correct response: to design a plan of care for and with the patient Explanation: The primary purpose of outcome identification and planning is to design a plan of care for and with the patient that, once implemented, results in the prevention, reduction, or resolution of patient health problems and the attainment of the patient's health expectations, as identified in the patient outcomes.
A new client presents in the acute care facility with several signs and symptoms of illness and disease. In order to determine and prioritize this client's healthcare needs, the nurses will: use a system to plan and implement care to reach desired outcomes. contact the physician before performing any other deeds. consult with other nurses to determine your first step. read up on the client's conditions before performing other tasks.
Correct response: use a system to plan and implement care to reach desired outcomes. Explanation: Clients present with multiple healthcare needs that the caregiver must approach in an organized, systematic manner to provide efficient and effective care. Providing healthcare is a process of problem solving.
The nurse is aware that what concepts are necessary for total implementation of the nursing process? Select all that apply. Excellent communication skills Critical thinking Problem solving Objective understanding Clinical reasoning
Critical thinking Problem solving Clinical reasoning The nursing process combines critical thinking, clinical reasoning, and problem-solving methods. Excellent communication skills and objective understanding are aspects of the nursing process but are not required concepts. Reference:
What statement does the nurse determine is a medical diagnosis rather than a nursing diagnosis? Fever of unknown origin Fluid volume excess Risk for falls Sleep-pattern disturbances
Fever of unknown origin Explanation: It is important to remember that nursing diagnoses are not medical diagnoses; they are not medical treatments prescribed by the physician, and they are not diagnostic studies. Rather, they are succinct statements in terms of specific patient problems that guide nurses in the development of the plan of nursing care. Fever of unknown origin is a medical diagnosis. The rest are nursing diagnoses.
