Nokea
Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis
- A. the patient is vulnerable to develop the problem
- B. there is no evidence of defining characteristics
- C. a condition is currently present
- D. it is written as a two-part statement
Correct Answer: C
Rationale: An actual nursing diagnosis (C) indicates a current condition with observable signs. A risk diagnosis (A) suggests potential for a problem. B is incorrect as actual diagnoses require evidence. D is incorrect as actual diagnoses use a three-part statement.
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Patient provided subjective data of intermittent chest pain upon exertion
Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:
- A. a head-to-toe assessment
- B. subjective data collection
- C. objective data collection
- D. Maslow's Hierarchy of Needs
Correct Answer: A
Rationale: A head-to-toe assessment (A) organizes a complete exam systematically. B and C are data types, not approaches, and D prioritizes needs, not physical exams.
Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:
- A. patient's nursing problem
- B. interventions carried out to meet the patient's needs
- C. patient's medical problem
- D. the patient's response to the intervention carried out
Correct Answer: B
Rationale: Documenting interventions, time, and signature (B) records actions taken to address patient needs, ensuring accountability. A and C relate to diagnoses, and D focuses on outcomes, not interventions.
Patient walks with a limp; Patient reports pain level as 3 on a scale of 1 to 10; Coughed up 5 mL yellow sputum; Headache in frontal area
The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)
- A. Assistive personnel reports the patient walks with a limp
- B. Patient reports pain level as 3 on a scale of 1 to 10
- C. Heart rate 72 beats per minute
- D. Respiratory rate 22 per minute with even unlabored respirations
- E. Coughed up 5 mL yellow sputum
- F. Headache in frontal area
Correct Answer: C,D,E
Rationale: C: Heart rate is measured, making it objective. D: Respiratory rate is observed and quantified, thus objective. E: Sputum volume and color are observable, hence objective. A is secondhand, B and F are subjective patient reports.
To what does objective data refer when assessing a patient?
- A. the provider's observed data
- B. All of the answers are correct
- C. the patient's perception of provided data
- D. the patient's request for information
Correct Answer: A
Rationale: Objective data (A) includes measurable findings by the provider, like vital signs. C and D are subjective, and B is incorrect as only A is accurate.
Patient with a nursing diagnosis of airway clearance, ineffective
The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:
- A. oxygen will be continued
- B. the patient's coughing frequency will increase
- C. cyanosis may be present
- D. within 24 hours, the patient will demonstrate no signs or symptoms of dyspnea
Correct Answer: D
Rationale: The desired outcome for ineffective airway clearance (D) is measurable improvement, like no dyspnea within 24 hours. A is an intervention, B does not ensure clearance, and C indicates worsening.