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A clinical judgment concerning a human response to health conditions/life processes or a vulnerability for that response by an individual family group or community is known as a nursing ____
Correct Answer: diagnosis
Rationale: A patient problem is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.
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A systemic dynamic way to collect and analyze data about a patient that includes physiologic data as well as psychological sociocultural spiritual economic and lifestyle factors is known as ____
Correct Answer: assessment
Rationale: The American Nurses Association (ANA) defines assessment as 'a systematic, dynamic way to collect and analyze data about a patient, the first step in delivering nursing care. Assessment includes not only physiologic data, but also psychological, sociocultural, spiritual, economic, and lifestyle factors as well.'
What subjective data does the nurse record following a head-to-toe examination?
- A. Rash on back
- B. Prolonged nausea
- C. Blood pressure of 190/100
- D. White blood cell count of 19000
Correct Answer: B
Rationale: Another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient.
During a physical examination the nurse discovers that the patient demonstrates signs of flushed dry hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent?
- A. Symptoms
- B. Data clustering
- C. Signs of fluid overload
- D. Urinary retention
Correct Answer: B
Rationale: The nurse organizes data, and those that are related are referred to as clustering. These are also signs of fluid overload.
The document that outlines a plan for care interventions over a specified time frame is called a clinical pathway critical path action plan or caremap.
Correct Answer: multidisciplinary
Rationale: A clinical pathway is an organized multidisciplinary plan over a specified time frame, which outlines aspects of patient care. They are also called critical paths, action plans, and care maps.
Which are official categories of patient problems?
- A. Actual
- B. Risk
- C. Wellness
- D. Syndrome
- E. Potential
Correct Answer: A,B,C,D
Rationale: Actual, risk, wellness, and syndrome are the four categories of patient problems.