Nokea
Select the proper order of the phases of the Nursing Process:
- A. Evaluation, planning, assessment, implementation
- B. Assessment, planning, implementation, evaluation
- C. Implementation, assessment, planning, evaluation
- D. Planning, evaluation, assessment, implementation
Correct Answer: B
Rationale: The nursing process follows a logical sequence: Assessment (data collection), Planning (developing goals and interventions), Implementation (executing the plan), and Evaluation (assessing effectiveness). Only option B lists this correct order.
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When discovering subjective data, recognize that they relate to:
- A. signs
- B. objective cues
- C. symptoms
- D. observable data
Correct Answer: C
Rationale: Subjective data relates to symptoms (C) reported by the patient, like pain or nausea. Signs (A), objective cues (B), and observable data (D) are objective, measurable findings.
Which of the following assists the nurse in the identification of nursing diagnoses?
- A. validated data
- B. data clustering
- C. subjective data
- D. objective data
Correct Answer: B
Rationale: Data clustering (B) groups related signs and symptoms to form nursing diagnoses. Validated (A), subjective (C), and objective (D) data are components but not the process of diagnosis.
The primary source of assessment information is:
- A. the patient's friends
- B. past medical records
- C. the patient's record
- D. the patient
Correct Answer: D
Rationale: The patient (D) is the primary source for assessment data, providing real-time information on symptoms and concerns. Friends (A) and records (B, C) are secondary sources and may not reflect current status.
Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:
- A. patient's nursing problem
- B. interventions carried out to meet the patient's needs
- C. patient's medical problem
- D. the patient's response to the intervention carried out
Correct Answer: B
Rationale: Documenting interventions, time, and signature (B) records actions taken to address patient needs, ensuring accountability. A and C relate to diagnoses, and D focuses on outcomes, not interventions.
Which part of the medical record can be used as evidence in court?
- A. the care plan
- B. the medical orders
- C. the entire record
- D. nursing notes
Correct Answer: C
Rationale: The entire record (C) can be used in court, providing a comprehensive view of care. A, B, and D are parts but not the whole.