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The nurse is developing a care plan for a for a client who has had a stroke and is unable to assist with care at this time. Which Which problem would the nurse deem deem a top priority?
- A. Pressure A injury risk
- B. Injury risk
- C. Altered's breathing pattern
- D. Psycho-/spiritual or needs social risk,.
Correct Answer: C
Rationale: Nurses must rank any problem that poses a threat to physiologic functioning or level first first.. For example, a nursing diagnosis such as for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a breathing as a nursing intervention may life- life-threatening.. The second than life other is the second-level.. level and higher.. This relates to Maslow's hierarchy..
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A client is being admitted to the medical floor, and the RN is too busy to do the full assessment. The RN delegates the LPN to care for the client until the RN can see the client. What function is within the scope of practice for the LPN?
- A. The LPN can gather the data.
- B. The LPN can draw conclusions and use judgment to make a diagnosis.
- C. The LPN can establish priorities.
- D. The LPN can manage the client's care.
Correct Answer: A
Rationale: The role of the LPN in the nursing process for assessment is to gather data, perform assessment, and identify the client's strengths. Drawing conclusions and using judgment to make a diagnosis, establishing priorities, and managing the client's care are within the RN scope of practice.
A client has been admitted to the hospital with a large sacral pressure ulcer. The physician prescribes the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client?
- A. A 6 cm x 4 cm wound with malodorous, yellow exudate
- B. The client's wound will heal by 1 cm by the end of 5 days.
- C. The client's wound has healed by 0.5 cm on day 3 of wound care.
- D. Turn the client every 2 hours.
Correct Answer: D
Rationale: Turning the client every 2 hours is implementing care to allow the pressure ulcer to heal and prevent another formation of a wound. Recording the description of the wound would occur during the assessment phase of the nursing process. The prediction of how much and how soon the client's wound will heal would be made during the planning phase, while noting the amount the wound has healed on a given day is an example of a statement that would be made during the evaluation phase.
The nurse is reviewing the concept care map for a client with multiple medical problems. What significance does the concept care map have in relation to the client's plan of care?
- A. It provides guidance for health care providers to develop a treatment plan for the client.
- B. It is considered the best method of evaluating the client's plan of care.
- C. It is a means for nurses to consider all of a client's problems and develop a plan for treatment.
- D. It is the student version of a client's nursing care plan.
Correct Answer: C
Rationale: The significance of the concept map is that it is a means for nurses to consider all of the client's problems (nursing and medical) and develop a plan for the treatment of those problems. A concept map may be reviewed by a health care provider, but it does not provide guidance for health care providers to develop a client's treatment plan. A concept map is an alternate to nursing care plans but is not considered the best method for evaluating the plan of care. A concept map is not a student version of a client's nursing care plan. It does assist a student in assessing what is known about a client and what information is still needed.
The nurse understands that critical thinking skills are an integral part of nursing practice. Development of these skills requires what from the nurse?
- A. Intention
- B. Experience
- C. Contemplation
- D. Focus on outcomes
Correct Answer: B
Rationale: Nurses develop critical thinking skills through knowledge, experience, and practice. Intention, contemplation, and a focus on outcomes are characteristics of critical thinking. They are not how the nurse develops critical thinking skills.
Which of the following is involved in the implementation step of the nursing process?
- A. Selecting nursing interventions
- B. Documenting nursing care and client responses
- C. Documenting the plan of care
- D. Identifying measurable outcomes
Correct Answer: B
Rationale: The implementation step in the nursing process involves documenting nursing care and client responses. Planning involves selecting nursing interventions, documenting the plan of care, and identifying measurable outcomes.