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A nurse admits a patient to the hospitals short-stay unit and completes a health history and physical assessment. Using these data, the nurse develops a(n) plan of care, based on planning?
- A. intermittent, focused
- B. comprehensive, initial
- C. single-use, ongoing
- D. standard, emergency
Correct Answer: B
Rationale: Upon admission, a nurse develops a comprehensive, initial plan of care (B) based on the health history and physical assessment.
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What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for patients within a case management healthcare delivery system?
- A. Kardex care plans
- B. computerized plans of care
- C. clinical pathways
- D. student care plans
Correct Answer: C
Rationale: Clinical pathways (C) are tools used to communicate standardized interdisciplinary care plans.
Which of the following outcomes is correctly written?
- A. Abdominal incision will show no signs of infection.
- B. On discharge, patient will be free of infection.
- C. On discharge, patient will be able to list five symptoms of infection.
- D. During home care, nurse will not observe symptoms of infection.
Correct Answer: C
Rationale: A correctly written outcome is specific, measurable, and patient-centered, such as the patient listing five symptoms of infection (C).
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.
Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? Select all that apply.
- A. professional physicians organizations
- B. state Nurse Practice Acts
- C. The Joint Commission
- D. the Agency for Health Care Research and Quality
- E. the Patient Health Partnership
- F. the Patient Bill of Rights
Correct Answer: B,C,D
Rationale: State Nurse Practice Acts (B), The Joint Commission (C), and the Agency for Health Care Research and Quality (D) are recognized standards that guide nursing practice and care planning.
Which of the following statements accurately describe the impact on nursing of using NIC/NOC standardized languages? Select all that apply.
- A. They demonstrate the impact that nurses have on the system of healthcare delivery.
- B. They standardize and define the knowledge base for nursing curricula and practice.
- C. They limit the number of appropriate nursing intervention to be selected.
- D. They hinder the teaching of clinical decision making to novice nurses.
- E. They enable researchers to examine the effectiveness and cost of nursing care.
- F. They slow the development and use of nursing information systems.
Correct Answer: A,B,E
Rationale: NIC/NOC languages demonstrate nursing impact (A), standardize knowledge (B), and enable research (E).