Nokea
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.
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When using the Five Steps of the Evidence-Informed Practice (EIP) Process, in which order should the nurse construct a clinical question?
- A. Comparison of interest
- B. Population of interest
- C. Outcome of interest
- D. Intervention of interest
- E. Timeframe
Correct Answer: A,B,C,D,E
Rationale: The order of the nurse's statements follows the PICOT format, which includes Population, Intervention, Comparison, Outcome, and Timeframe, in that order.
Which of the following would the nurse perform during the assessment phase of the nursing process?
- A. Obtains data with which to diagnose patient problems.
- B. Uses patient data to develop priority nursing diagnoses.
- C. Teaches interventions to relieve patient health problems.
- D. Assists the patient to identify realistic outcomes to health problems.
Correct Answer: A
Rationale: During the assessment phase, the nurse gathers information about the patient. The other responses are examples of the intervention, diagnosis, and planning phases of the nursing process.
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.
Which action by a newly graduated RN working on the postsurgical unit indicates that more education about delegation and assignment is needed?
- A. The nurse delegates measurement of patient oral intake and urine output to an unregulated care provider.
- B. The nurse delegates assessment of a patient's bowel sounds to an experienced unregulated care provider.
- C. The nurse assigns an LPN/RPN to administer oral medications to several patients.
- D. The nurse assigns a 'float' RN from pediatrics to care for a patient with diabetes.
Correct Answer: B
Rationale: Assessment requires RN education and scope of practice and cannot be delegated to an unregulated care provider. The other actions by the new RN are appropriate.
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.