Nokea
A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?
- A. that the written outcomes are designed to meet nursing goals
- B. to encourage the patient and family to be involved
- C. to discourage additions by other healthcare providers
- D. why the nurse believes the outcome is important
Correct Answer: B
Rationale: Involving the patient and family (B) is crucial for developing patient-centered outcomes.
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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.
In which of the following patients has the order of priorities for nursing diagnoses changed? Select all that apply.
- A. a patient in a long-term care facility who had a stroke
- B. a patient who is recovering from a broken leg
- C. a patient who insists on using the bathroom instead of a bedpan
- D. a patient who appears confused after taking pain medication
- E. a pregnant patient whose contractions are progressing as anticipated
- F. a patient who has wounds that require stitches as well as a concussion
Correct Answer: A,C,D,F
Rationale: Patients with a stroke (A), insistence on bathroom use (C), confusion after medication (D), and wounds plus concussion (F) may have shifting priorities due to acute or changing conditions.
Which of the following groups of terms best describes a nurse-initiated intervention?
- A. dependent, physician-ordered, recovery
- B. autonomous, clinical judgment, patient outcomes
- C. medical diagnosis, medication administration
- D. other healthcare providers, skill acquisition
Correct Answer: B
Rationale: Nurse-initiated interventions are autonomous, based on clinical judgment, and aimed at patient outcomes (B).
Which of the following are verbs that are helpful in writing measurable outcomes? Select all that apply.
- A. know
- B. define
- C. hear
- D. verbalize
- E. feel
- F. list
Correct Answer: B,D,F
Rationale: Verbs like define (B), verbalize (D), and list (F) are measurable and action-oriented, suitable for writing outcomes.
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).