Nokea
In which phase of the nursing process does the nurse select interventions to assist the patient to meet the needs demonstrated?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: During the planning phase, the nurse connects nursing interventions to nursing orders.
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Which is an example of a medical diagnosis?
- A. Pain
- B. Anxiety
- C. Pneumonia
- D. Impaired skin integrity
Correct Answer: C
Rationale: Pneumonia is the only example of a medical diagnosis; all other options are examples of patient problems.
What framework does the establishment of priorities of care during the planning phase of the nursing process often use?
- A. Erikson's developmental tasks
- B. Piaget's cognitive table
- C. Maslow's hierarchy of needs
- D. Freud's classifications
Correct Answer: C
Rationale: A useful framework to guide prioritization is Maslow's hierarchy of needs.
A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date it is determined that what has occurred?
- A. Omission
- B. Variance
- C. Failure
- D. Error
Correct Answer: B
Rationale: A variance occurs when a projected outcome is not met.
A nurse is formulating a patient problem. What is an example of an appropriately written patient problem?
- A. Risk for impaired skin integrity related to physical immobilization
- B. Physical immobilization secondary to risk for impaired skin integrity
- C. Risk for impaired skin integrity related to diagnosis of decubitus ulcers
- D. Physical immobilization secondary to decreased cognitive ability
Correct Answer: A
Rationale: Risk for impaired skin integrity related to physical immobilization is the only appropriately written patient problem. All other options are not listed as NANDA-I approved patient problems.
Which is an example of a medical diagnosis?
- A. Constipation
- B. Diabetes mellitus
- C. Impaired skin integrity
- D. Altered nutrition: less than body requirements
Correct Answer: B
Rationale: Diabetes mellitus is the only example of a medical diagnosis; all other options are examples of patient problems.