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A nursing diagnosis may be a one-part, two-part, or three-part statement.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Nursing diagnoses can be structured as one-part (wellness), two-part (problem and etiology), or three-part (problem, etiology, and symptoms) statements.
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In which step of the nursing process would you look at outcomes?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: E
Rationale: Evaluation is the step where nurses assess whether the patient has achieved the expected outcomes, determining the effectiveness of the care plan.
Nursing diagnoses all contain the modifier 'risk for.'
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. Only potential problems use 'risk for'; actual problems and wellness diagnoses do not.
You have passed your NCLEX-PN examination and have just been employed as an LPN on a medical surgical unit. The registered nurse (RN) in charge asks you to do the admission assessment on a new patient who has just arrived by ambulance from a long-term care facility. The patient had undergone a total hip replacement within the previous 2 weeks and has developed a fever. You tell the nurse you thought an LPN could not do the admission assessment or, at most, could do only certain portions of it. The nurse, who is very busy, says, 'Please just do it. I'll cosign it, so it will be fine.' Which of the following actions should you take next?
- A. Call the supervisor to discuss the nurse's instructions to you.
- B. Refuse to do the admission assessment but offer to get the patient settled in, take his vital signs, and review the chart for orders.
- C. Check the facility's policy manual.
- D. Do the assessment as requested.
Correct Answer: B,C
Rationale: Checking the facility's policy manual (C) ensures you act within your scope of practice. Refusing to do the admission assessment but offering to perform tasks within your role (B) is appropriate, as LPNs typically cannot perform initial admission assessments, which are reserved for RNs.
Which step of the nursing process is concerned with identifying physical findings?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: A
Rationale: Assessment is the step where nurses collect data, including physical findings, through observation, interviews, and examinations to establish a baseline for patient care.
By using a problem statement, the cause of the problem, and the defining characteristics of the problem, nursing diagnoses help identify interventions to address the problem.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Nursing diagnoses include a problem statement, etiology, and defining characteristics to guide targeted interventions.