Nokea
A nurse is formulating a patient problem. What is an example of an appropriately written patient problem?
- A. Risk for impaired skin integrity related to physical immobilization
- B. Physical immobilization secondary to risk for impaired skin integrity
- C. Risk for impaired skin integrity related to diagnosis of decubitus ulcers
- D. Physical immobilization secondary to decreased cognitive ability
Correct Answer: A
Rationale: Risk for impaired skin integrity related to physical immobilization is the only appropriately written patient problem. All other options are not listed as NANDA-I approved patient problems.
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Human responses to health conditions and life processes that may develop in a vulnerable individual family or community are known as a(n) ____ patient problem.
Correct Answer: risk
Rationale: A risk patient problem is defined as the human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.
Which is an example of a medical diagnosis?
- A. Pain
- B. Anxiety
- C. Pneumonia
- D. Impaired skin integrity
Correct Answer: C
Rationale: Pneumonia is the only example of a medical diagnosis; all other options are examples of patient problems.
What is the primary purpose of nursing interventions?
- A. To support health care provider's orders
- B. To provide direction for all caregivers
- C. To provide broad general statements
- D. To clarify nursing principles
Correct Answer: B
Rationale: Nursing orders are necessary to provide instructions for all caregivers.
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.
The human responses to health conditions/life processes that exist in an individual family or community are known as a(n) ____ patient problem.
Correct Answer: actual
Rationale: An actual patient problem is described as the human responses to health conditions/life processes that exist in an individual, family, or community.