Nokea
NANDA International meets to reorganize diagnosis labels and language every 2 ____
Correct Answer: years
Rationale: NANDA International meets every two years to revise language, form, and diagnosis labels.
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During a physical examination the nurse discovers that the patient demonstrates signs of flushed dry hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent?
- A. Symptoms
- B. Data clustering
- C. Signs of fluid overload
- D. Urinary retention
Correct Answer: B
Rationale: The nurse organizes data, and those that are related are referred to as clustering. These are also signs of fluid overload.
What is a patient problem considered when a problem is suspected but data to support it are lacking?
- A. A syndrome patient problem
- B. An actual patient problem
- C. A "risk for" diagnosis
- D. A possible patient problem
Correct Answer: D
Rationale: A possible patient problem requires additional data to confirm a problem or to complete a data cluster so that it can be related to a NANDA-I label.
What expected outcome exemplifies accepted criteria?"
- A. Nurse will assess vital signs every day
- B. Resident will observe safety guidelines while smoking
- C. Resident will take part in one activity daily for the next 90 days
- D. Nurse will monitor O2 saturation to maintain at greater than 90%
Correct Answer: C
Rationale: Expected outcomes must be patient-centered, measurable, and refer to a time frame.
Human responses to health conditions and life processes that may develop in a vulnerable individual family or community are known as a(n) ____ patient problem.
Correct Answer: risk
Rationale: A risk patient problem is defined as the human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.
A multidisciplinary plan that schedules clinical ____ over an anticipated time frame for high-risk high-volume and high-cost types of cases is known as a critical pathway.
Correct Answer: interventions
Rationale: A critical pathway is a multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases.