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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.
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A nurse admits a patient to the hospitals short-stay unit and completes a health history and physical assessment. Using these data, the nurse develops a(n) plan of care, based on planning?
- A. intermittent, focused
- B. comprehensive, initial
- C. single-use, ongoing
- D. standard, emergency
Correct Answer: B
Rationale: Upon admission, a nurse develops a comprehensive, initial plan of care (B) based on the health history and physical assessment.
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).
A nurse records patient data on a folded card and places it in a central file, where it is easily accessible to staff. Which system of care is this nurse using?
- A. critical pathways
- B. case management
- C. Kardex care plan
- D. concept map care plan
Correct Answer: C
Rationale: A Kardex care plan (C) involves recording patient data on a folded card for staff access.
Which of the following are verbs that are helpful in writing measurable outcomes? Select all that apply.
- A. know
- B. define
- C. hear
- D. verbalize
- E. feel
- F. list
Correct Answer: B,D,F
Rationale: Verbs like define (B), verbalize (D), and list (F) are measurable and action-oriented, suitable for writing outcomes.
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.