Nokea
Which is an example of a medical diagnosis?
- A. Constipation
- B. Diabetes mellitus
- C. Impaired skin integrity
- D. Altered nutrition: less than body requirements
Correct Answer: B
Rationale: Diabetes mellitus is the only example of a medical diagnosis; all other options are examples of patient problems.
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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.
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.
The standards that name and measure patient ____ are referred to as NOC (Nursing Outcome Classification).
Correct Answer: outcomes
Rationale: NOC sets up outcome criteria based on a patient problem.
What expected outcome exemplifies accepted criteria?"
- A. Nurse will assess vital signs every day
- B. Resident will observe safety guidelines while smoking
- C. Resident will take part in one activity daily for the next 90 days
- D. Nurse will monitor O2 saturation to maintain at greater than 90%
Correct Answer: C
Rationale: Expected outcomes must be patient-centered, measurable, and refer to a time frame.
Which are acceptable secondary sources for data?
- A. Patient
- B. Family members
- C. Other health professionals
- D. Diagnostic reports
- E. Textbooks
Correct Answer: B,C,D,E
Rationale: A patient is not a secondary source. The patient is the primary data source.