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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.
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You are assisting the nurse practitioner (NP) with her assessment of an elderly, confused woman. You watch as the NP places her hand on the woman's back and then taps her own middle finger with her other hand. This assessment technique is called
- A. Inspection
- B. Palpation
- C. Auscultation
- D. Percussion
Correct Answer: D
Rationale: Percussion involves tapping to assess underlying structures, as described in the NP's technique.
LPNs/LVNs do not have a role in determining nursing diagnoses for the care plan.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. LPNs/LVNs contribute to care planning by collecting data and providing input, though RNs typically finalize nursing diagnoses.
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.
The NANDA-I list of nursing diagnoses is the only source of nursing diagnoses available.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. While NANDA-I is a widely used source, other standardized nursing diagnosis lists exist, and nurses may develop diagnoses based on patient needs.
Implementation means putting the plan into action and performing the interventions.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Implementation involves executing the planned nursing interventions to achieve patient goals.