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Which of the following illustrates a common error when writing patient outcomes?
- A. Patient will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m.
- B. Patient will demonstrate correct sequence of exercises by next office visit.
- C. Patient will be less anxious and fearful before and after surgery.
- D. On discharge, patient will list five symptoms of infection to report.
Correct Answer: C
Rationale: Less anxious and fearful' (C) is vague and not measurable, a common error in outcome writing.
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The nursing diagnosis Impaired Gas Exchange, prioritized by Maslows hierarchy of basic human needs, is appropriate for what level of needs?
- A. physiologic
- B. safety
- C. love and belonging
- D. self-actualization
Correct Answer: A
Rationale: Impaired Gas Exchange relates to breathing, a physiologic need (A), which is the most basic level in Maslow's hierarchy.
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.
A nurse is using a structured care methodology that follows a set of steps based on a clinicians decision process to help standardize nursing care plans. What is the term for this element of a structured care methodology?
- A. algorithm
- B. national guidelines
- C. standard of care
- D. clinical practice guideline
Correct Answer: A
Rationale: An algorithm (A) is a set of steps based on a clinician's decision process to standardize care plans.
Which of the following is an example of a well-stated nursing intervention?
- A. Patient will drink 100 mL of water every 2 hours while awake.
- B. Offer patient 100 mL of water every 2 hours while awake.
- C. Offer patient water when he complains of thirst.
- D. Patient will continue to increase oral intake when awake.
Correct Answer: B
Rationale: A well-stated nursing intervention is nurse-focused and specific, such as offering water every 2 hours (B).
A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what patient need should have priority?
- A. the need to have nutrition
- B. the need to feel good about oneself
- C. the need to live in a safe environment
- D. the need for love from others
Correct Answer: B
Rationale: The patient's refusal to eat until her appearance is addressed indicates that her need to feel good about herself (B) is currently the priority.