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Which of the following is involved in the implementation step of the nursing process?
- A. Selecting nursing interventions
- B. Documenting nursing care and client responses
- C. Documenting the plan of care
- D. Identifying measurable outcomes
Correct Answer: B
Rationale: The implementation step in the nursing process involves documenting nursing care and client responses. Planning involves selecting nursing interventions, documenting the plan of care, and identifying measurable outcomes.
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The LPN is collecting data so that the RN may develop the plan of care for the client. What is the importance of accurate gathering of baseline data?
- A. The physician will be able to make a diagnosis.
- B. It serves as a comparison for future signs and symptoms
- C. The RN will be able to make the assignments based on the baseline data.
- D. The RN will know what type of medication the client will receive.
Correct Answer: B
Rationale: The client database includes all the information obtained from the medical and nursing history, physical examination, and diagnostic studies. Baseline data serve as a comparison for future signs and symptoms and provide a reference for determining if a client's health is improving. The physician does not use the care plan for the diagnosis.
Which of the following is a true statement about critical thinking in nursing?
- A. It involves purposeful, outcome-directed thinking.
- B. It shows trends and patterns in client status.
- C. It makes judgments based on conjecture.
- D. It supplies validation for reimbursement.
Correct Answer: A
Rationale: In nursing, critical thinking involves purposeful, outcome-directed thinking. Critical thinking makes judgments based on evidence rather than conjecture. Providing a foundation for evaluation and quality improvement and showing trends and patterns in client status are functions served by documentation.
The nurse is prioritizing the care of a client who has a diagnosis of uncontrolled diabetes and may have the left foot amputated related to a nonhealing ulcer. What need would the nurse place at the lowest level of Maslow's hierarchy while prioritizing this client's care?
- A. Physiologic needs
- B. Safety and security needs
- C. Love and belonging needs
- D. Self-actualization needs
Correct Answer: D
Rationale: Self-actualization needs are the fifth and last level of Maslow's hierarchy. Physiologic needs are the first level, safety and security needs are the second level, and love and belonging needs are the third level.
A nurse is creating a plan of care and has identified several problems for the client including a collaborative problem. Which statement distinguishes a collaborative problem from a problem-focused nursing diagnosis?
- A. A collaborative problem addresses the problem's related risk factors and defining characteristics.
- B. A collaborative problem denotes a complication that has a physiologic origin which can be addressed by independent and/or health care provider prescribed nursing interventions.
- C. A collaborative problem denotes a client's response to a physiologic condition that can be addressed solely by nursing interventions.
- D. A collaborative problem is a secondary risk factor that provides a more in-depth explanation of the problem.
Correct Answer: B
Rationale: Collaborative problems denote complications with a physiologic origin and differ from nursing diagnoses, which address client responses to various circumstances and are managed by nursing interventions. Related risk factors and defining characteristics are parts of a nursing diagnosis, not a collaborative problem. A nursing diagnosis describes a client's response to a physiologic condition or the environment and can be addressed by nursing interventions (independent or health care provider prescribed). Secondary risk factors can provide a more in-depth explanation of the cause of a problem in a nursing diagnosis. Collaborative problems do not have secondary risk factors.
A nurse and a student are developing a concept care map for a client with multiple sclerosis. Once finished, what important information can the student glean from the concept map?
- A. Ideas about the client's care and how they are linked and interrelated
- B. A prediction of how effective the client's plan of care will be
- C. Trends and patterns in the client's status over time
- D. A determination of whether the desired outcomes are achieved
Correct Answer: A
Rationale: The student can glean important information pertaining to ideas about the client's care and how these ideas are linked and interrelated. A concept map does not predict how effective the client's plan of care will be. That requires the nurse to evaluate the plan's effectiveness. The concept map also does not provide trends and patterns in the client's status over time. That requires the nurse to assess and document those trends. To determine if desired outcomes are achieved, the nurse needs to reassess the client once the plan of care has been implemented.