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A nurse records patient data on a folded card and places it in a central file, where it is easily accessible to staff. Which system of care is this nurse using?
- A. critical pathways
- B. case management
- C. Kardex care plan
- D. concept map care plan
Correct Answer: C
Rationale: A Kardex care plan (C) involves recording patient data on a folded card for staff access.
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A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what patient need should have priority?
- A. the need to have nutrition
- B. the need to feel good about oneself
- C. the need to live in a safe environment
- D. the need for love from others
Correct Answer: B
Rationale: The patient's refusal to eat until her appearance is addressed indicates that her need to feel good about herself (B) is currently the priority.
What common problem is related to outcome identification and planning?
- A. failing to involve the patient in the planning process
- B. collecting sufficient data to establish a database
- C. stating specific and measurable outcomes based on nursing diagnoses
- D. writing nursing orders that are clear and resolve the problem
Correct Answer: A
Rationale: A common problem is failing to involve the patient (A), which can lead to non-patient-centered plans.
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).
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.
A nurse is using a structured care methodology that follows a set of steps based on a clinicians decision process to help standardize nursing care plans. What is the term for this element of a structured care methodology?
- A. algorithm
- B. national guidelines
- C. standard of care
- D. clinical practice guideline
Correct Answer: A
Rationale: An algorithm (A) is a set of steps based on a clinician's decision process to standardize care plans.