Nokea
Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning?
- A. How do I best cluster these data and cues to identify problems?
- B. What problems require my immediate attention or that of the team?
- C. What major defining characteristics are present for a nursing diagnosis?
- D. How do I document care accurately and legally?
Correct Answer: B
Rationale: During outcome identification and planning, critical thinking involves prioritizing issues, so asking which problems need immediate attention (B) facilitates this process.
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A nurse admits a patient to the hospitals short-stay unit and completes a health history and physical assessment. Using these data, the nurse develops a(n) plan of care, based on planning?
- A. intermittent, focused
- B. comprehensive, initial
- C. single-use, ongoing
- D. standard, emergency
Correct Answer: B
Rationale: Upon admission, a nurse develops a comprehensive, initial plan of care (B) based on the health history and physical assessment.
What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
- A. problem statement
- B. defining characteristics
- C. etiology of the problem
- D. outcomes criteria
Correct Answer: C
Rationale: The etiology of the problem (C) guides the selection of nursing interventions by addressing the cause.
Although each care plan is individualized, there are certain risks and health problems that, for example, patients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?
- A. initial
- B. ongoing
- C. discharge
- D. standardized
Correct Answer: D
Rationale: Standardized care plans (D) address common risks and health problems for patients with similar treatments.
A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what patient need should have priority?
- A. the need to have nutrition
- B. the need to feel good about oneself
- C. the need to live in a safe environment
- D. the need for love from others
Correct Answer: B
Rationale: The patient's refusal to eat until her appearance is addressed indicates that her need to feel good about herself (B) is currently the priority.
Which of the following illustrates a common error when writing patient outcomes?
- A. Patient will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m.
- B. Patient will demonstrate correct sequence of exercises by next office visit.
- C. Patient will be less anxious and fearful before and after surgery.
- D. On discharge, patient will list five symptoms of infection to report.
Correct Answer: C
Rationale: Less anxious and fearful' (C) is vague and not measurable, a common error in outcome writing.