Nokea
A nurse documents the following diagnosis for a hospitalized patient: Risk for Imbalanced Nutrition: More Than Body Requirements. What is the major goal of interventions for a risk diagnosis?
- A. reduce or eliminate contributing factors
- B. prevent the problem
- C. collect additional data
- D. promote higher-level wellness
Correct Answer: B
Rationale: The major goal for a risk diagnosis is to prevent the problem from occurring by addressing risk factors and implementing preventive measures.
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Which of the following examples of nursing actions involve direct care of the patient? Select all that apply.
- A. A nurse counsels a young family who is interested in natural family planning.
- B. A nurse massages the back of a patient while performing a skin assessment.
- C. A nurse arranges for a consultation for a patient who has no health insurance.
- D. A nurse helps a patient in hospice fill out a living will form.
- E. A nurse arranges for physical therapy for a patient who had a stroke.
- F. A nurse comforts a distraught patient whose baby was stillborn.
Correct Answer: A,B,D,F
Rationale: Direct care involves hands-on or face-to-face interaction with the patient. Counseling (A), massaging (B), assisting with a living will (D), and comforting (F) involve direct patient interaction, whereas arranging consultations (C) and physical therapy (E) are indirect care activities.
Which of the following statements accurately describe a recommended guideline for implementation? Select all that apply.
- A. When implementing nursing care, remember to act independently, regardless of the wishes of the patient/family.
- B. Before implementing any nursing action, reassess the patient to determine whether the action is still needed.
- C. Assume that the nursing intervention selected is the best of all possible alternatives.
- D. Consult colleagues and the nursing and related literature to see if other approaches might be more successful.
- E. Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.
- F. Check to make sure that the nursing interventions selected are consistent with standards of care.
Correct Answer: B,D,F
Rationale: Recommended guidelines include reassessing the patient (B), consulting colleagues and literature for better approaches (D), and ensuring interventions align with standards of care (F). Acting independently without patient input (A), assuming interventions are the best (C), or reducing skills (E) are not recommended.
What phrase best describes nurse-initiated interventions?
- A. nurse-prescribed interventions
- B. physician-prescribed interventions
- C. healthcare team interventions
- D. interventions based on medical orders
Correct Answer: A
Rationale: Nurse-initiated interventions are best described as nurse-prescribed, as they are independently ordered by nurses based on their scope of practice and patient needs.
Each time a nurse administers an insulin injection to a patient with diabetes, she tells the patient what she is doing and demonstrates each step of preparing and giving the injection. What is the nurse promoting?
- A. self-care
- B. dependence
- C. coping with disability
- D. nursepatient relationship
Correct Answer: A
Rationale: By explaining and demonstrating the injection process, the nurse is teaching the patient how to manage their condition, promoting self-care.
What activity is carried out during the implementing step of the nursing process?
- A. Assessments are made to identify human responses to health problems.
- B. Mutual goals are established and desired patient outcomes are determined.
- C. Planned nursing actions (interventions) are carried out.
- D. Desired outcomes are evaluated and, if necessary, the plan is modified.
Correct Answer: C
Rationale: The implementing step involves carrying out planned nursing interventions to address the patient's needs, as outlined in the nursing care plan.