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Patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg
Your patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg. Which nursing diagnosis would apply to this patient's immediate needs?
- A. pain
- B. skin integrity
- C. fluid volume
- D. knowledge deficit
Correct Answer: A
Rationale: Pain (A) is the immediate need due to severe discomfort, requiring urgent management. Skin integrity (B), fluid volume (C), and knowledge deficit (D) are secondary.
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When using the SOAP method of charting, S stands for subjective data which means:
- A. patient provided data
- B. all of the answers are correct
- C. observed data
- D. measured data
Correct Answer: A
Rationale: Subjective data (A) includes patient-reported information like pain or symptoms. Observed (C) and measured (D) data are objective, and B is incorrect as only A is accurate.
Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:
- A. CNA
- B. Technician
- C. RN
- D. LPN/LVN
Correct Answer: C
Rationale: The RN (C) is responsible for analyzing data and formulating nursing diagnoses, as it requires critical thinking within their scope of practice. CNAs (A) and Technicians (B) assist with care but do not diagnose. LPNs/LVNs (D) collect data but do not formulate diagnoses.
Patient health care records are:
- A. not used by anyone else but the direct care providers
- B. concise, legal records of all care given and responses
- C. owned by the patient, who has a right to see the data any time he/she wishes
- D. confidential information and cannot be taken to court
Correct Answer: B
Rationale: Records (B) are legal, concise documentation of care and responses, used by multiple parties. A, C, and D are incorrect regarding usage, ownership, and legal status.
Patient with dyspnea
The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:
- A. implementation
- B. evaluation
- C. planning
- D. assessment
Correct Answer: C
Rationale: Planning (C) involves selecting interventions for patient needs, like dyspnea. A, B, and D represent other phases.
Patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation
During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:
- A. signs of fluid overload
- B. symptoms
- C. data clustering
- D. urinary retention
Correct Answer: C
Rationale: Grouping signs like flushed skin and fever (C) is data clustering, suggesting dehydration or infection. Fluid overload (A) shows edema, symptoms (B) are subjective, and urinary retention (D) involves bladder issues.