Nokea
You are performing the daily assessment of your patient's status. You notice some purplish marks on her arm where the bandage for her IV had been and the skin is torn. Which of the following techniques did you use to obtain these data?
- A. Inspection
- B. Palpation
- C. Auscultation
- D. Percussion
Correct Answer: A
Rationale: Inspection involves visually observing the patient's skin, which allowed you to notice the purplish marks and torn skin.
You may also like to solve these questions
When a patient achieves the expected outcome, the nursing diagnosis is resolved.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Achieving the expected outcome indicates the nursing diagnosis has been addressed, resolving the problem.
Wellness diagnoses are characterized by the phrase 'ready for enhanced.'
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Wellness diagnoses, such as 'ready for enhanced health,' focus on opportunities for health improvement.
Nursing diagnoses and medical diagnoses both use the names of diseases.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False. Nursing diagnoses focus on patient responses to health conditions, not disease names, which are used in medical diagnoses.
You enter the room to find your patient ashen and gasping for breath. Which part of the nursing process should you perform, formally or informally, in the first 5 minutes?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
- F. All of the above
Correct Answer: F
Rationale: In an emergency, nurses perform all steps of the nursing process rapidly: assessing the patient's condition, diagnosing the problem, planning immediate actions, implementing interventions, and evaluating their effectiveness.
In which step of the nursing process are priorities set?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: C
Rationale: Planning involves setting priorities for nursing diagnoses and determining goals and interventions to address the patient's needs.