Nokea
A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase Disturbed Self-Esteem identify?
- A. the expected outcome of the plan of care
- B. a cue to determining a health problem
- C. the major defining characteristic of a health problem
- D. the health state or problem of the patient
Correct Answer: D
Rationale: Disturbed Self-Esteem' identifies the patient's health state or problem in the nursing diagnosis.
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What is the focus of a diagnostic statement for a collaborative problem?
- A. the patient problem
- B. the potential complication
- C. the nursing diagnosis
- D. the medical diagnosis
Correct Answer: B
Rationale: Collaborative problems focus on potential complications that require both nursing and medical interventions to manage.
A nurse caring for an elderly patient in a long-term care facility notices that the bedding is wet when the patient gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?
- A. no problem
- B. possible problem
- C. actual problem
- D. clinical problem
Correct Answer: B
Rationale: Wet bedding suggests a possible problem, such as incontinence, but further data collection is needed to confirm.
A nurse develops a plan of care to meet the needs of a patient who has had a large loss of blood after a snowmobile crash. The interventions include administering and monitoring the patients physiologic response to intravenous fluids and blood. What has the nurse focused care on?
- A. a medical diagnosis
- B. a nursing diagnosis
- C. a collaborative problem
- D. a goal for care
Correct Answer: C
Rationale: This scenario describes a collaborative problem, as it involves joint interventions between nursing and medical care, such as administering fluids and blood.
After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a patient. What are the nursing diagnoses used for?
- A. selecting nursing interventions to meet expected outcomes
- B. establishing a database of information for future comparison
- C. mutually establishing desired outcomes of the plan of care
- D. evaluating the effectiveness of the established plan of care
Correct Answer: A
Rationale: Nursing diagnoses guide the selection of interventions to achieve expected outcomes, as they provide a framework for addressing patient needs.
Which of the following statements accurately describe the legal responsibility of the nurse making a diagnosis for a patient?
- A. The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the patient.
- B. The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the patient.
- C. The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it.
- D. The healthcare facility directs the nursing diagnosis in order to receive payment for services performed.
Correct Answer: C
Rationale: Nurses are legally responsible for ensuring they are qualified to make a nursing diagnosis and for the treatment that follows, as it falls within their scope of practice.