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The nurse is caring for a patient who has been admitted to the hospital for surgery and tells the nurse, 'I do not feel right about leaving my children with my neighbour.' Which action should the nurse take next?
- A. Reassure the patient that these feelings are common for parents.
- B. Have the patient call the children to ensure that they are doing well.
- C. Call the neighbour to determine whether adequate childcare is being provided.
- D. Gather more data about the patient's feelings about the childcare arrangements.
Correct Answer: D
Rationale: Since a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the nurse's first action should be to obtain more information. The other actions may be appropriate, but more assessment is needed before the best intervention can be chosen.
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Which of the following represents a nursing activity that is carried out during the evaluation phase of the nursing process?
- A. Determining if interventions have been effective in meeting patient outcomes.
- B. Documenting the nursing care plan in the progress notes in the medical record.
- C. Deciding whether the patient's health problems have been completely resolved.
- D. Asking the patient to evaluate whether the nursing care provided was satisfactory.
Correct Answer: A
Rationale: Evaluation consists of determining whether the desired patient outcomes have been met and whether the nursing interventions were appropriate. The other responses do not describe the evaluation phase.
The nurse is caring for a patient who has left-sided paralysis as the result of a stroke and assesses a pressure injury on the patient's left hip. Which of the following is the most appropriate nursing diagnosis for this patient?
- A. Impaired physical mobility related to decrease in muscle control (left-sided paralysis)
- B. Risk for impaired tissue integrity as evidenced by insufficient knowledge about protecting tissue integrity
- C. Impaired skin integrity related to pressure over bony prominence (impaired circulation)
- D. Ineffective peripheral tissue perfusion related to sedentary lifestyle
Correct Answer: C
Rationale: The patient's major problem is the impaired skin integrity as demonstrated by the presence of a pressure injury. The nurse is able to treat the cause of impaired circulation and pressure over bony prominence by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The 'risk for' diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective peripheral tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is.
Which of the following includes the components required for a complete nursing diagnosis statement?
- A. A problem and the suggested patient goals or outcomes.
- B. A problem, its cause, and objective data that support the problem
- C. A problem with all its possible causes and the planned interventions
- D. A problem with its etiology and the signs and symptoms of the problem
Correct Answer: D
Rationale: The PES format is used when writing nursing diagnoses. The subjective, as well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the nursing diagnosis statement.
The nurse is caring for a patient with a new diagnosis of pneumonia and explains to the patient that together they will plan the patient's care and set goals for discharge. The patient asks: 'How is that different from what the doctor does?' Which response by the nurse is most appropriate?
- A. The role of the nurse is to administer medications and other treatments prescribed by your doctor.
- B. The nurse's job is to help the doctor by collecting data and communicating when there are problems.
- C. Nurses perform many of the procedures done by physicians, but nurses are here in the hospital for a longer time than doctors.
- D. In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.
Correct Answer: D
Rationale: This response is consistent with the Canadian Nurses Association (CNA) definition of nursing. Registered nurses are self-regulated health care professionals who work autonomously and in collaboration with others. RNs enable individuals, families, groups, communities and populations to achieve their optimal level of health. RNs coordinate health care, deliver direct services, and support patients in their self-care decisions and actions in situations of health, illness, injury, and disability in all stages of life. The other responses describe some of the dependent and collaborative functions of the nursing role but do not accurately describe the nurse's role in the health care system.
Which of the following is an example of a correctly written nursing diagnosis statement?
- A. Altered tissue perfusion related to heart failure
- B. Risk for impaired tissue integrity related to sacral redness
- C. Ineffective coping related to insufficient sense of control
- D. Altered urinary elimination related to urinary tract infection
Correct Answer: C
Rationale: This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patient's response to a health problem that can be treated by nursing. The use of a medical diagnosis (as in the responses beginning 'Altered tissue perfusion' and 'Altered urinary elimination') is not appropriate. The response beginning 'Risk for impaired tissue integrity' uses the defining characteristics as the etiology.