Nokea
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.
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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.
How is Maslow's hierarchy of human needs used by nurses in a clinical setting?
- A. It serves as a reminder of human growth and development across the life span.
- B. It is a framework for thinking critically.
- C. It helps in prioritizing nursing diagnoses and care.
- D. It outlines the basic psychological needs that people have when they are hospitalized and feeling vulnerable.
Correct Answer: C
Rationale: Maslow's hierarchy helps nurses prioritize care by addressing physiological needs first, followed by safety, love, esteem, and self-actualization, ensuring patient needs are met in order of urgency.
Which step of the nursing process is most associated with action?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: D
Rationale: Implementation is the action-oriented step where nurses carry out the planned interventions to address patient needs.
LPNs/LVNs do not have a role in determining nursing diagnoses for the care plan.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. LPNs/LVNs contribute to care planning by collecting data and providing input, though RNs typically finalize nursing diagnoses.
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.