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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.
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Which are acceptable secondary sources for data?
- A. Patient
- B. Family members
- C. Other health professionals
- D. Diagnostic reports
- E. Textbooks
Correct Answer: B,C,D,E
Rationale: A patient is not a secondary source. The patient is the primary data source.
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.
What type of assessment is performed continuously throughout nurse-patient contact?
- A. Complete
- B. Body systems
- C. Focused
- D. Subjective
Correct Answer: C
Rationale: Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan.
A systematic method by which nurses plan and provide care for patients is known as the nursing ____
Correct Answer: process
Rationale: The nursing process serves as the organizational framework for the practice of nursing. It is a systematic method by which nurses plan and provide care for patients.
NANDA International meets to reorganize diagnosis labels and language every 2 ____
Correct Answer: years
Rationale: NANDA International meets every two years to revise language, form, and diagnosis labels.