Nokea
What assists the nurse in the identification of patient problems?
- A. Objective data
- B. Subjective data
- C. Data clustering
- D. Validated data
Correct Answer: C
Rationale: Data clustering assists the nurse in determining patient problems.
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When the nurse is prioritizing care during the planning phase of the nursing process what is the guiding framework?
- A. Primary
- B. Secondary
- C. Unreliable
- D. Biased
Correct Answer: B
Rationale: Secondary sources include family members.
Which is an example of a medical diagnosis?
- A. Pain
- B. Anxiety
- C. Pneumonia
- D. Impaired skin integrity
Correct Answer: C
Rationale: Pneumonia is the only example of a medical diagnosis; all other options are examples of patient problems.
What is an important consideration when developing the care plan?
- A. Ensure the number of interventions is limited.
- B. Ensure the patient is involved in the process.
- C. Ensure interventions will be easy to implement.
- D. Ensure evaluation of the patient problems is possible.
Correct Answer: B
Rationale: Plans are more effective when the patient is involved in the process. The care plan is not limited in terms of the number of interventions, nor do they have to be easy. The patient problems are not evaluated; the patient's progress toward the outcome is.
What documentation reflects implementation?
- A. Patient selected low-sugar snacks independently.
- B. Patient was medicated with Tylenol 500 mg PO for pain.
- C. Patient was ambulated for 15 minutes after lunch.
- D. Patient participated in group therapy session without reminder.
Correct Answer: C
Rationale: Implementation is the nurse carrying out nursing orders to promote outcome achievement.
All of the following patients have been admitted to the acute care setting. On admission which patient should receive a focused assessment?
- A. 53-year-old admitted with a perforated ulcer
- B. 5-year-old admitted for the implant of grommets in the middle ear
- C. 76-year-old admitted for a knee replacement
- D. 40-year-old admitted for possible bowel obstruction
Correct Answer: A
Rationale: A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses.