chapter 5 Assessment, Nursing Diagnosis, and Planning My Nursing Test Banks – Flashcards
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When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _______ data.
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subjective
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The major goal of the admission interview (usually performed by the RN) is to
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identify the patients major complaints.
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An example of a structured format for gathering data that aids in forming a database is
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Gordons 11 Health Patterns.
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During the assessment phase of the nursing process, the nurse
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gathers, organizes, and documents data in a logical database.
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After the admission assessment is completed, on subsequent shifts or days, the nurse
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assesses the patient briefly in the first hour of the shift.
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The nurse performing an admission interview on an elderly person should
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allow more time for a response to questions.
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A nursing diagnosis consists of
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diagnostic labels formulated by the North American Nursing Diagnosis Association International (NANDA-I).
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An elderly patient with a medical diagnosis of chronic lung disease has developed pneumonia. She is coughing frequently and expectorating thick, sticky secretions. She is very short of breath, even with oxygen running, and she is exhausted and says she cant breathe. Based on this information, an appropriately worded nursing diagnosis for this patient is
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Airway clearance, ineffective, related to lung secretions as evidenced by cough and shortness of breath.
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If a patient has several nursing diagnoses, the nurse will first
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prioritize the nursing problems according to Maslows hierarchy of needs.
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A patient has a nursing diagnosis of Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30-pounds over the last 6 months. An appropriate short-term goal for this patient is to
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eat 50% of six small meals each day by the end of 1 week.
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The nursing diagnoses that has the highest priority is
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Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating.
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A patient with visual impairment is identified as at risk for falls related to blindness. An appropriate intervention would be to
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arrange furnishings in room to provide clear pathways and orient the patient to these.
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The North American Nursing Diagnosis AssociationI (NANDA-I) list is revised and updated every
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2 years.
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A nursing care plan consists of
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nursing orders for individualized interventions to assist the patient to meet expected outcomes.
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In an acute care facility, a nursing care plan is usually reviewed and updated
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every 24 hours.
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The nurse takes into consideration that the difference between a sign and a symptom is that a sign is
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can be verified by examination.
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The nurse clarifies that nursing orders are also called
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interventions.
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The nurse designs the goals for patients in long-term facilities to be
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long-term.
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Standardized Nursing Care Plans can
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have items altered or deleted.
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A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is
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Airway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung.
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Conclusions that have been made based on observed data are __________.
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inferences
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The nurse understands that an expected outcome should be: (Select all that apply.)
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realistic. attainable. within a defined time. included after patient collaboration.
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A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurologic impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.)
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Assist with range-of-motion exercises every 4 hours and as needed. Instruct patient to call for assistance when needing to get out of bed. Teach about exercises that will strengthen muscles while lying in bed. Ambulate with physical therapy assistance at least three times a day.
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Appropriate nursing roles in the initial assessment would include: (Select all that apply.)
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LPN obtains the vital signs of a new patient. RN performs a complete physical assessment. RN reviews the patients chart for past medical/surgical history. LVN contributes ongoing assessments.
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Aside from the information obtained from the patient (primary source) in the admission interview, the nurse will also access: (Select all that apply.)
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the patients family. the admission note. the physicians history and physical. an observation of the patient for non-verbal clues.
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A nursing diagnosis identifies: (Select all that apply.)
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patients response to illness. related signs and symptoms. causative factors. potential risk for health problems.
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The statements that are correctly stated as expected outcomes are: (Select all that apply.)
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Patient will be able to ambulate using a walker independently within 3 days. Patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours.
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The nurse should make a point when closing the initial interview to: (Select all that apply.)
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summarize the problems discussed. thank the patient for his or her time.
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The seven domains of the Nursing Interventions Classification (NIC) taxonomy include: (Select all that apply.)
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community. health system. safety. behavioral.
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The purpose of the Nursing Outcomes Classification (NOC) is to: (Select all that apply.)
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validate classification by field test. identify labels. provide language labels for desired outcomes. identify patient outcomes and indicators.
