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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.
You may also like to solve these questions
Implementation means putting the plan into action and performing the interventions.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Implementation involves executing the planned nursing interventions to achieve patient goals.
Specified diagnoses are those that clearly apply to one defined patient need, so that any more description would only be redundant.
- A. TRUE
- B. FALSE
Correct Answer: A
Rationale: True. Specified diagnoses are concise and address a single, clear patient need without unnecessary elaboration.
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.
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.
In which step of the nursing process do you label problems?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
- E. Evaluation
Correct Answer: B
Rationale: Diagnosis is the step where nurses analyze assessment data to identify and label patient problems as nursing diagnoses.