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Which are official categories of patient problems?
- A. Actual
- B. Risk
- C. Wellness
- D. Syndrome
- E. Potential
Correct Answer: A,B,C,D
Rationale: Actual, risk, wellness, and syndrome are the four categories of patient problems.
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During an admission assessment the nurse collects objective and subjective data. What is an example of subjective data?
- A. The patient is asleep.
- B. The patient is tearful.
- C. The patient has facial grimacing.
- D. The patient states "I hurt all over."
Correct Answer: D
Rationale: Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Stating 'I hurt all over' is an example of subjective data. All other options are examples of objective data.
Which is an example of a patient problem?
- A. Pneumonia
- B. Diabetes mellitus
- C. Impaired skin integrity
- D. Congestive heart failure
Correct Answer: C
Rationale: Impaired skin integrity is the only example of a patient problem; all other options are examples of medical diagnoses.
What is the basis for designing and selecting nursing interventions to meet patient needs?
- A. Patient problem
- B. Care plan
- C. Health care provider's orders
- D. Nurse's notes
Correct Answer: A
Rationale: The patient problem is the basis for developing nursing interventions.
During an admission assessment the nurse collects objective and subjective data. What is an example of objective data?
- A. The patient complains of feeling depressed.
- B. The patient states "I hear voices in my head."
- C. The patient complains of auditory hallucinations.
- D. The patient is pacing back and forth while chanting.
Correct Answer: D
Rationale: Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Pacing back and forth while chanting is an example of objective data. All other options are examples of subjective data.
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.