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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.
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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.
Human responses to health conditions and life processes that may develop in a vulnerable individual family or community are known as a(n) ____ patient problem.
Correct Answer: risk
Rationale: A risk patient problem is defined as the human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.
From where are the "risk for" patient problems identified?
- A. The care plan
- B. The interventions
- C. The assessment
- D. The evaluation
Correct Answer: C
Rationale: Patient problems should be identified from the assessment.
The patient is confined to bed rest which contributes to immobility. What is bed rest considered in this situation?
- A. Contributing to the patient's recovery
- B. A risk factor
- C. Difficult to maintain
- D. A nursing responsibility
Correct Answer: B
Rationale: Risk factors are those that increase the susceptibility of a patient to a problem.
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.