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Which of these is considered subjective data?
- A. The patient is resting on his side.
- B. The patient complains of a headache.
- C. The patient ambulated to the bathroom with assistance.
- D. The patient's mother states that he does not eat well.
Correct Answer: B, D
Rationale: Subjective data includes patient or family reports, such as complaints of a headache or statements about eating habits.
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Given that all of the following are appropriate nursing diagnoses for your patient, which would be the priority?
- A. Ineffective coping
- B. Sedentary lifestyle
- C. Risk for loneliness
- D. Self-care deficit: bathing
Correct Answer: D
Rationale: Per Maslow's hierarchy, physiological needs like self-care deficits take priority over psychosocial needs like coping or loneliness.
Which are examples of independent nursing interventions?
- A. Placing a patient on intake and output measurement
- B. Assessing the abdomen when a patient is constipated
- C. Encouraging high-fiber foods for a patient who is constipated
- D. Administering an enema to a constipated patient
- E. Administering a laxative and stool softener to a constipated patient
Correct Answer: A, C
Rationale: Independent interventions, like monitoring intake/output and encouraging dietary changes, do not require a physician's order.
Which of the following are examples of activities in which a nurse would need to use critical thinking?
- A. Prioritizing patient care
- B. Administering medications
- C. Writing nursing orders
- D. Questioning the appropriateness of an order
- E. Starting an IV infusion
Correct Answer: A, D
Rationale: Prioritizing care and questioning orders require critical thinking to assess and make informed decisions.
Which of these nursing diagnoses is correctly written?
- A. Readiness for enhanced knowledge related to problems with diabetes
- B. Risk for injury related to poor balance when walking
- C. Risk for falls as manifested by frequent falls in the past
- D. Anxiety and fear
Correct Answer: B
Rationale: Risk for injury related to poor balance when walking' follows NANDA-I format with a diagnostic label and etiology.
Number in order the steps of the nursing process.
- A. Planning
- B. Assessment
- C. Evaluation
- D. Diagnosis
- E. Implementation
Correct Answer: B, D, A, E, C
Rationale: The nursing process sequence is: Assessment, Diagnosis, Planning, Implementation, Evaluation.