Nokea
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?
- A. no priority
- B. low priority
- C. medium priority
- D. high priority
Correct Answer: D
Rationale: Impaired Gas Exchange in a non-breathing child is a life-threatening condition, making it a high-priority diagnosis (D).
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What is true of nursing responsibilities with regard to a physician-initiated intervention (physicians order)?
- A. Nurses do not carry out physician-initiated interventions.
- B. Nurses do carry out interventions in response to a physicians order.
- C. Nurses are responsible for reminding physicians to implement orders.
- D. Nurses are not legally responsible for these interventions.
Correct Answer: B
Rationale: Nurses are responsible for carrying out physician-initiated interventions (B) as part of their role.
What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
- A. problem statement
- B. defining characteristics
- C. etiology of the problem
- D. outcomes criteria
Correct Answer: C
Rationale: The etiology of the problem (C) guides the selection of nursing interventions by addressing the cause.
From what part of the nursing diagnoses are outcomes derived during outcome identification and planning?
- A. problem statement
- B. defining characteristics
- C. etiology of the problem
- D. outcomes criteria
Correct Answer: C
Rationale: Outcomes are derived from the etiology of the problem (C), as addressing the cause helps formulate measurable goals.
A nurse assesses the vital signs of a patient who is one day postsurgery in which a colostomy was performed. The nurse then uses the data to update the patient plan of care. What are these actions considered?
- A. initial planning
- B. comprehensive planning
- C. on-going planning
- D. discharge planning
Correct Answer: C
Rationale: Updating the care plan based on new assessments, such as post-surgery vital signs, is considered ongoing planning (C).
Although each care plan is individualized, there are certain risks and health problems that, for example, patients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?
- A. initial
- B. ongoing
- C. discharge
- D. standardized
Correct Answer: D
Rationale: Standardized care plans (D) address common risks and health problems for patients with similar treatments.