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In which of the following patients has the order of priorities for nursing diagnoses changed? Select all that apply.
- A. a patient in a long-term care facility who had a stroke
- B. a patient who is recovering from a broken leg
- C. a patient who insists on using the bathroom instead of a bedpan
- D. a patient who appears confused after taking pain medication
- E. a pregnant patient whose contractions are progressing as anticipated
- F. a patient who has wounds that require stitches as well as a concussion
Correct Answer: A,C,D,F
Rationale: Patients with a stroke (A), insistence on bathroom use (C), confusion after medication (D), and wounds plus concussion (F) may have shifting priorities due to acute or changing conditions.
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Which of the following is an example of a well-stated nursing intervention?
- A. Patient will drink 100 mL of water every 2 hours while awake.
- B. Offer patient 100 mL of water every 2 hours while awake.
- C. Offer patient water when he complains of thirst.
- D. Patient will continue to increase oral intake when awake.
Correct Answer: B
Rationale: A well-stated nursing intervention is nurse-focused and specific, such as offering water every 2 hours (B).
A nurse is using a structured care methodology that follows a set of steps based on a clinicians decision process to help standardize nursing care plans. What is the term for this element of a structured care methodology?
- A. algorithm
- B. national guidelines
- C. standard of care
- D. clinical practice guideline
Correct Answer: A
Rationale: An algorithm (A) is a set of steps based on a clinician's decision process to standardize care plans.
A nurse records patient data on a folded card and places it in a central file, where it is easily accessible to staff. Which system of care is this nurse using?
- A. critical pathways
- B. case management
- C. Kardex care plan
- D. concept map care plan
Correct Answer: C
Rationale: A Kardex care plan (C) involves recording patient data on a folded card for staff access.
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.
A father runs into the emergency room with his 18 -month-old son in his arms. The father screams, Help, he is not breathing! The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?
- A. no priority
- B. low priority
- C. medium priority
- D. high priority
Correct Answer: D
Rationale: Impaired Gas Exchange in a non-breathing child is a life-threatening condition, making it a high-priority diagnosis (D).