Nokea
Improvement in a patient's health problem is measured by how much progress the patient makes toward the goal, which is set by the nurse.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. Goals are set collaboratively with the patient, not solely by the nurse, to ensure patient-centered care.
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A student in your class is given the name of a patient for whom she will provide care the following day in clinical. She goes to the unit, which specializes in diabetes care, to find out information and sees the patient sitting in a wheelchair with his chart in his lap. He is on his way to radiology for an x-ray. She notes that his left leg is amputated just below the knee and that his right foot is bandaged. Your class has been studying diabetes and the student knows that vascular problems and amputations are unfortunate complications of diabetes. She plans to study about diabetic foot care tonight so that she will be prepared for clinical the next day. Which of the following represents an accurate statement about her decision to study diabetic foot care?
- A. It reflects careful observation and good planning.
- B. The amputation and bandage are pretty obvious, so her plan is just common sense.
- C. She should read the patient's specific foot care program before reading about general diabetic foot care.
- D. She has made a serious thinking error.
Correct Answer: A,C
Rationale: The student's decision reflects careful observation and good planning (A) because she is proactively preparing for clinical by studying relevant content based on her observations. Additionally, reading the patient's specific foot care program first (C) would ensure her study is tailored to the patient's needs, enhancing her preparation.
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.
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.
Your patient has severe peripheral vascular disease (poor circulation) in both lower extremities. You document that the patient's pedal pulses are absent. Which assessment technique did you use to obtain these data?
- A. Inspection
- B. Palpation
- C. Auscultation
- D. Percussion
Correct Answer: B
Rationale: Palpation is used to feel for pedal pulses, determining their presence or absence.
Specified diagnoses are those that clearly apply to one defined patient need, so that any more description would only be redundant.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Specified diagnoses are concise and address a single, clear patient need without unnecessary elaboration.