Deck 10: Diagnosing; and Outcome Identification and Planning

Question 1

A nurse admits a patient to the hospital's short-stay unit and completes a health history and physical assessment. Using these data, the nurse develops a(n) ___________plan of care, based on _____________ planning?

A) intermittent, focused
B) comprehensive, initial
C) single-use, ongoing
D) standard, emergency

Answer 1

B

Question 2

Although each care plan is individualized, there are certain risks and health problems that, for example, patients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?

A) initial
B) ongoing
C) discharge
D) standardized

Answer 2

D

Question 3

A nurse assesses the vital signs of a patient who is one day postsurgery in which a colostomy was performed. The nurse then uses the data to update the patient plan of care. What are these actions considered?

A) initial planning
B) comprehensive planning
C) on-going planning
D) discharge planning

Answer 3

C

Question 4

A father runs into the emergency room with his 18-month-old son in his arms. The father screams, "Help, he is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?

A) no priority
B) low priority
C) medium priority
D) high priority

Question 5

A nurse writes down the following outcome for a depressed patient: "By 6/9/12, the patient will state three positive benefits of receiving counseling." This is an example of which of the following types of outcomes?

A) psychomotor
B) cognitive
C) affective
D) realistic

Question 6

Which of the following is categorized as a psychomotor outcome?

A) Within 2 days of teaching, the patient's wife will demonstrate abdominal dressing change.
B) Within 1 week of attending class, the patient will have cut smoking from 20 to 10 cigarettes per day.
C) The patient will verbalize understanding of need to continue to take medications as prescribed.
D) The patient's skin will remain smooth, moist, and without breakdown or ulceration.

Question 7

Which of the following are verbs that are helpful in writing measurable outcomes? Select all that apply.

A) know
B) define
C) hear
D) verbalize
E) feel
F) list

Question 8

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

A) Nurses do not carry out physician-initiated interventions.
B) Nurses do carry out interventions in response to a physician's order.
C) Nurses are responsible for reminding physicians to implement orders.
D) Nurses are not legally responsible for these interventions.

Question 9

A nurse is using a structured care methodology that follows a set of steps based on a clinician's decision process to help standardize nursing care plans. What is the term for this element of a structured care methodology?

A) algorithm
B) national guidelines
C) standard of care
D) clinical practice guideline

Question 10

A nurse records patient data on a folded card and places it in a central file, where it is easily accessible to staff. Which system of care is this nurse using?

A) critical pathways
B) case management
C) Kardex care plan
D) concept map care plan

Question 11

Which of the following are examples of nursing responsibilities? Select all that apply.

A) recognizing the signs and symptoms of pancreatitis when it presents in a patient
B) making a diagnosis of uterine cancer following diagnostic testing
C) referring a patient diagnosed with lung cancer to a smoke-cessation group
D) researching and prescribing medication for an adolescent with uncontrolled asthma
E) performing range-of-motion exercises on an elderly patient who is in a wheelchair
F) teaching a group of high school students about the dangers of having unprotected sex

Question 12

The nurse takes a patient's vital signs and finds the pulse rate to be 120 beats/min. What would the nurse do next to interpret and analyze this pulse rate?

A) Compare the patient's pulse rate to the standard range.
B) Notify the patient's healthcare provider.
C) Document the pulse in the appropriate chart page.
D) Ask another nurse to verify the pulse rate.

Question 13

Which of the following nursing diagnoses is an example of a wellness diagnosis?

A) Acute Pain
B) Risk for Infection
C) Readiness for Enhanced Parenting
D) Possible Chronic Low Self-Esteem