Nokea
In which step of the nursing process do you label problems?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: B
Rationale: Diagnosis is the step where nurses analyze assessment data to identify and label patient problems as nursing diagnoses.
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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.
In which step of the nursing process are priorities set?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: C
Rationale: Planning involves setting priorities for nursing diagnoses and determining goals and interventions to address the patient's needs.
The NANDA-I list of nursing diagnoses is the only source of nursing diagnoses available.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. While NANDA-I is a widely used source, other standardized nursing diagnosis lists exist, and nurses may develop diagnoses based on patient needs.
Nursing diagnoses and medical diagnoses both use the names of diseases.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. Nursing diagnoses focus on patient responses to health conditions, not disease names, which are used in medical diagnoses.
You enter the room to find your patient ashen and gasping for breath. Which part of the nursing process should you perform, formally or informally, in the first 5 minutes?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
- F. All of the above
Correct Answer: F
Rationale: In an emergency, nurses perform all steps of the nursing process rapidly: assessing the patient's condition, diagnosing the problem, planning immediate actions, implementing interventions, and evaluating their effectiveness.