Nokea
Which of the following pieces of information is included in the client database?
- A. Nursing care
- B. Diagnostic studies
- C. Plan of care
- D. Collaborative problems
Correct Answer: B
Rationale: The client database includes all the information obtained from the medical and nursing history, physical examination, and diagnostic studies. The client database does not include nursing care, plan of care, or collaborative problems.
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The nurse is reviewing the concept care map for a client with multiple medical problems. What significance does the concept care map have in relation to the client's plan of care?
- A. It provides guidance for health care providers to develop a treatment plan for the client.
- B. It is considered the best method of evaluating the client's plan of care.
- C. It is a means for nurses to consider all of a client's problems and develop a plan for treatment.
- D. It is the student version of a client's nursing care plan.
Correct Answer: C
Rationale: The significance of the concept map is that it is a means for nurses to consider all of the client's problems (nursing and medical) and develop a plan for the treatment of those problems. A concept map may be reviewed by a health care provider, but it does not provide guidance for health care providers to develop a client's treatment plan. A concept map is an alternate to nursing care plans but is not considered the best method for evaluating the plan of care. A concept map is not a student version of a client's nursing care plan. It does assist a student in assessing what is known about a client and what information is still needed.
Which of the following is the highest level of human need according to Maslow (1968)?
- A. Physiologic
- B. Love and belonging
- C. Esteem and self-esteem
- D. Self-actualization
Correct Answer: D
Rationale: The highest level need is self-actualization. The first level of need is physiological needs. Love and belonging are third-level needs. Esteem and self-esteem are fourth-level needs.
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.
A client has been admitted to the hospital with a large sacral pressure ulcer. The physician prescribes the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client?
- A. A 6 cm x 4 cm wound with malodorous, yellow exudate
- B. The client's wound will heal by 1 cm by the end of 5 days.
- C. The client's wound has healed by 0.5 cm on day 3 of wound care.
- D. Turn the client every 2 hours.
Correct Answer: D
Rationale: Turning the client every 2 hours is implementing care to allow the pressure ulcer to heal and prevent another formation of a wound. Recording the description of the wound would occur during the assessment phase of the nursing process. The prediction of how much and how soon the client's wound will heal would be made during the planning phase, while noting the amount the wound has healed on a given day is an example of a statement that would be made during the evaluation phase.
A client is admitted to the hospital for control of diabetes mellitus. When does the nurse understand the nursing process begins?
- A. When the client enters the healthcare system
- B. Prior to the client being discharged
- C. After the nurse initiates the plan of care
- D. When the health care provider writes the first prescription for care
Correct Answer: A
Rationale: The nursing process begins when a client enters the healthcare system. Prior to being discharged, after the plan of care is initiated, and when the healthcare provider writes the first prescription for care all occur after the client is already in the healthcare system.