Nokea
The standards that name and measure patient ____ are referred to as NOC (Nursing Outcome Classification).
Correct Answer: outcomes
Rationale: NOC sets up outcome criteria based on a patient problem.
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In which phase of the nursing process does the nurse select interventions to assist the patient to meet the needs demonstrated?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: During the planning phase, the nurse connects nursing interventions to nursing orders.
The nurse writes two patient problems: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses?
- A. The second diagnosis needs no defined nursing interventions.
- B. The second diagnosis needs medical intervention.
- C. The second diagnosis will not need to be evaluated.
- D. The second diagnosis reflects a problem that does not yet exist.
Correct Answer: D
Rationale: The actual patient problem represents a condition that is currently present. 'Risk for' diagnoses are those that the patient is susceptible to, but not yet troubled by.
What best defines the nursing process?
- A. A method to ensure that the health care provider's orders are implemented correctly.
- B. A series of assessments that isolate a patient's health problem.
- C. A framework for the organization of individualized nursing care.
- D. A preset formula for the design of nursing care.
Correct Answer: C
Rationale: The nursing process is a framework by which to organize individualized nursing care.
During a physical examination the nurse discovers that the patient demonstrates signs of flushed dry hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent?
- A. Symptoms
- B. Data clustering
- C. Signs of fluid overload
- D. Urinary retention
Correct Answer: B
Rationale: The nurse organizes data, and those that are related are referred to as clustering. These are also signs of fluid overload.
A multidisciplinary plan that schedules clinical ____ over an anticipated time frame for high-risk high-volume and high-cost types of cases is known as a critical pathway.
Correct Answer: interventions
Rationale: A critical pathway is a multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases.