Nokea
The evaluation step of the nursing process is the step in which the plan of care is either changed or continued.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Evaluation determines whether the care plan is effective, leading to its continuation, modification, or termination.
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You are assisting the nurse practitioner (NP) with her assessment of an elderly, confused woman. You watch as the NP places her hand on the woman's back and then taps her own middle finger with her other hand. This assessment technique is called
- A. Inspection
- B. Palpation
- C. Auscultation
- D. Percussion
Correct Answer: D
Rationale: Percussion involves tapping to assess underlying structures, as described in the NP's technique.
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.
Which step of the nursing process is concerned with identifying physical findings?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: A
Rationale: Assessment is the step where nurses collect data, including physical findings, through observation, interviews, and examinations to establish a baseline for patient care.
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.
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.