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What is the primary purpose of the outcome identification and planning step of the nursing process?
- A. to collect and analyze data to establish a database
- B. to interpret and analyze data to identify health problems
- C. to write appropriate patient-centered nursing diagnoses
- D. to design a plan of care for and with the patient
Correct Answer: D
Rationale: The outcome identification and planning step focuses on establishing patient-centered goals and designing a plan of care collaboratively with the patient, making D the correct choice.
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What common problem is related to outcome identification and planning?
- A. failing to involve the patient in the planning process
- B. collecting sufficient data to establish a database
- C. stating specific and measurable outcomes based on nursing diagnoses
- D. writing nursing orders that are clear and resolve the problem
Correct Answer: A
Rationale: A common problem is failing to involve the patient (A), which can lead to non-patient-centered plans.
A father runs into the emergency room with his 18 -month-old son in his arms. The father screams, Help, he is not breathing! The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?
- A. no priority
- B. low priority
- C. medium priority
- D. high priority
Correct Answer: D
Rationale: Impaired Gas Exchange in a non-breathing child is a life-threatening condition, making it a high-priority diagnosis (D).
Which of the following statements accurately describe the impact on nursing of using NIC/NOC standardized languages? Select all that apply.
- A. They demonstrate the impact that nurses have on the system of healthcare delivery.
- B. They standardize and define the knowledge base for nursing curricula and practice.
- C. They limit the number of appropriate nursing intervention to be selected.
- D. They hinder the teaching of clinical decision making to novice nurses.
- E. They enable researchers to examine the effectiveness and cost of nursing care.
- F. They slow the development and use of nursing information systems.
Correct Answer: A,B,E
Rationale: NIC/NOC languages demonstrate nursing impact (A), standardize knowledge (B), and enable research (E).
What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
- A. problem statement
- B. defining characteristics
- C. etiology of the problem
- D. outcomes criteria
Correct Answer: C
Rationale: The etiology of the problem (C) guides the selection of nursing interventions by addressing the cause.
A nurse is discharging a patient from the hospital. When should discharge planning be initiated?
- A. at the time of discharge from an acute healthcare setting
- B. at the time of admission to an acute healthcare setting
- C. before admission to an acute healthcare setting
- D. when the patient is at home after acute care
Correct Answer: B
Rationale: Discharge planning should begin at the time of admission (B) to ensure a smooth transition and continuity of care.