Nokea
When a patient achieves the expected outcome, the nursing diagnosis is resolved.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Achieving the expected outcome indicates the nursing diagnosis has been addressed, resolving the problem.
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You enter the room to find your patient ashen and gasping for breath. Which part of the nursing process should you perform, formally or informally, in the first 5 minutes?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
- F. All of the above
Correct Answer: F
Rationale: In an emergency, nurses perform all steps of the nursing process rapidly: assessing the patient's condition, diagnosing the problem, planning immediate actions, implementing interventions, and evaluating their effectiveness.
Which step of the nursing process is concerned with identifying physical findings?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: A
Rationale: Assessment is the step where nurses collect data, including physical findings, through observation, interviews, and examinations to establish a baseline for patient care.
A student in your class is given the name of a patient for whom she will provide care the following day in clinical. She goes to the unit, which specializes in diabetes care, to find out information and sees the patient sitting in a wheelchair with his chart in his lap. He is on his way to radiology for an x-ray. She notes that his left leg is amputated just below the knee and that his right foot is bandaged. Your class has been studying diabetes and the student knows that vascular problems and amputations are unfortunate complications of diabetes. She plans to study about diabetic foot care tonight so that she will be prepared for clinical the next day. Which of the following represents an accurate statement about her decision to study diabetic foot care?
- A. It reflects careful observation and good planning.
- B. The amputation and bandage are pretty obvious, so her plan is just common sense.
- C. She should read the patient's specific foot care program before reading about general diabetic foot care.
- D. She has made a serious thinking error.
Correct Answer: A,C
Rationale: The student's decision reflects careful observation and good planning (A) because she is proactively preparing for clinical by studying relevant content based on her observations. Additionally, reading the patient's specific foot care program first (C) would ensure her study is tailored to the patient's needs, enhancing her preparation.
By using a problem statement, the cause of the problem, and the defining characteristics of the problem, nursing diagnoses help identify interventions to address the problem.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Nursing diagnoses include a problem statement, etiology, and defining characteristics to guide targeted interventions.
In which step of the nursing process would you look at outcomes?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: E
Rationale: Evaluation is the step where nurses assess whether the patient has achieved the expected outcomes, determining the effectiveness of the care plan.