Nokea
Specified diagnoses are those that clearly apply to one defined patient need, so that any more description would only be redundant.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Specified diagnoses are concise and address a single, clear patient need without unnecessary elaboration.
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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.
You are caring for a male patient who had a total hip replacement 3 days earlier. You have not cared for the patient before and are assessing him to establish a baseline of information about his health status. The patient states he felt feverish during the night and broke into a sweat. You check his temperature readings from the previous night and see that it was 99.2?°F at midnight and 98.2?°F at 6 a.m. It now is 99?°F. Which of the following actions represents the best response to his statement and gives the best explanation for the action as it relates to critical thinking?
- A. Tell him not to worry because his temperature was only 99.2?°F. This action shows that you understand normal trends in postoperative care and are applying them to unique situations.
- B. Make a mental note to check his temperature a few more times this shift. This action shows that you understand that assessment is the first and most important step in the nursing process.
- C. Assess him for signs and symptoms of an infection. This action shows that you are looking for data to validate the patient's comment.
- D. Tell him that a low-grade fever is normal after surgery. This shows that you are aware of common clinical conditions.
Correct Answer: C
Rationale: Assessing for signs and symptoms of infection (C) is the best response as it involves critical thinking by validating the patient's subjective complaint with objective data, ensuring a thorough evaluation of a potential postoperative complication.
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.
A nursing diagnosis may be a one-part, two-part, or three-part statement.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Nursing diagnoses can be structured as one-part (wellness), two-part (problem and etiology), or three-part (problem, etiology, and symptoms) statements.
Wellness diagnoses are characterized by the phrase 'ready for enhanced.'
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Wellness diagnoses, such as 'ready for enhanced health,' focus on opportunities for health improvement.