Nokea
Which of the following includes the components required for a complete nursing diagnosis statement?
- A. A problem and the suggested patient goals or outcomes.
- B. A problem, its cause, and objective data that support the problem
- C. A problem with all its possible causes and the planned interventions
- D. A problem with its etiology and the signs and symptoms of the problem
Correct Answer: D
Rationale: The PES format is used when writing nursing diagnoses. The subjective, as well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the nursing diagnosis statement.
You may also like to solve these questions
Which of these tasks is appropriate for the registered nurse to delegate to an unregulated care provider?
- A. Perform a sterile dressing change for an infected wound.
- B. Complete the patients' initial bath.
- C. Teach a patient about the effects of prescribed medications.
- D. Document patient teaching about a routine surgical procedure.
Correct Answer: B
Rationale: Unregulated care providers are able to provide personal care to patients. Patient teaching and the initial assessment and development of the plan of care are nursing actions that require RN-level education and scope of practice when working with patients that are not stable.
The nurse is caring for a patient who has left-sided paralysis as the result of a stroke and assesses a pressure injury on the patient's left hip. Which of the following is the most appropriate nursing diagnosis for this patient?
- A. Impaired physical mobility related to decrease in muscle control (left-sided paralysis)
- B. Risk for impaired tissue integrity as evidenced by insufficient knowledge about protecting tissue integrity
- C. Impaired skin integrity related to pressure over bony prominence (impaired circulation)
- D. Ineffective peripheral tissue perfusion related to sedentary lifestyle
Correct Answer: C
Rationale: The patient's major problem is the impaired skin integrity as demonstrated by the presence of a pressure injury. The nurse is able to treat the cause of impaired circulation and pressure over bony prominence by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The 'risk for' diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective peripheral tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is.
Which of the following represents a nursing activity that is carried out during the evaluation phase of the nursing process?
- A. Determining if interventions have been effective in meeting patient outcomes.
- B. Documenting the nursing care plan in the progress notes in the medical record.
- C. Deciding whether the patient's health problems have been completely resolved.
- D. Asking the patient to evaluate whether the nursing care provided was satisfactory.
Correct Answer: A
Rationale: Evaluation consists of determining whether the desired patient outcomes have been met and whether the nursing interventions were appropriate. The other responses do not describe the evaluation phase.
When using the Five Steps of the Evidence-Informed Practice (EIP) Process, in which order should the nurse construct a clinical question?
- A. Comparison of interest
- B. Population of interest
- C. Outcome of interest
- D. Intervention of interest
- E. Timeframe
Correct Answer: A,B,C,D,E
Rationale: The order of the nurse's statements follows the PICOT format, which includes Population, Intervention, Comparison, Outcome, and Timeframe, in that order.
The nurse is caring for a critically ill patient in the intensive care unit and plans an every-2-hour turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this turning schedule?
- A. Dependent
- B. Cooperative
- C. Independent
- D. Collaborative
Correct Answer: D
Rationale: When implementing collaborative nursing actions, the nurse is responsible primarily for monitoring for complications of acute illness or providing care to prevent or treat complications. Independent nursing actions are focused on health promotion, illness prevention, and patient advocacy. A dependent action would require a physician order to implement. Cooperative nursing functions are not described as one of the formal nursing functions.