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A systemic dynamic way to collect and analyze data about a patient that includes physiologic data as well as psychological sociocultural spiritual economic and lifestyle factors is known as ____
Correct Answer: assessment
Rationale: The American Nurses Association (ANA) defines assessment as 'a systematic, dynamic way to collect and analyze data about a patient, the first step in delivering nursing care. Assessment includes not only physiologic data, but also psychological, sociocultural, spiritual, economic, and lifestyle factors as well.'
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Which are considered phases of the nursing process?
- A. Diagnosis
- B. Prediction
- C. Assessment
- D. Evaluation
- E. Implementation
- F. Outcome identification
Correct Answer: A,C,D,E,F
Rationale: The nursing process consists of six dynamic and interrelated phases: diagnosis, assessment, outcome identification, planning, implementation, and evaluation. Prediction is not a phase of the nursing process.
During a physical examination the nurse discovers that the patient demonstrates signs of flushed dry hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent?
- A. Symptoms
- B. Data clustering
- C. Signs of fluid overload
- D. Urinary retention
Correct Answer: B
Rationale: The nurse organizes data, and those that are related are referred to as clustering. These are also signs of fluid overload.
What type of assessment is performed continuously throughout nurse-patient contact?
- A. Complete
- B. Body systems
- C. Focused
- D. Subjective
Correct Answer: C
Rationale: Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan.
The patient is confined to bed rest which contributes to immobility. What is bed rest considered in this situation?
- A. Contributing to the patient's recovery
- B. A risk factor
- C. Difficult to maintain
- D. A nursing responsibility
Correct Answer: B
Rationale: Risk factors are those that increase the susceptibility of a patient to a problem.
A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date it is determined that what has occurred?
- A. Omission
- B. Variance
- C. Failure
- D. Error
Correct Answer: B
Rationale: A variance occurs when a projected outcome is not met.