MULTIPLE CHOICE Y
Ajlnurse is completing a care plan for a child and is finishing the assessment
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phase. Whichactivity is not part of a nursing assessment?
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Y FY FY FY FY FY FY FY
a. Writing nursing diagnoses FY FY
b. Reviewing diagnostic reports FY FY
c. Collecting data FY
d. Setting priorities FY
ANS: D FY
Setting priorities is a part of planning. Writing nursing diagnoses, reviewing
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diagnostic reports,and collecting data are parts of assessment.
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Y FY FY FY FY FY FY
DIF: Cognitive Level: Comprehension REF: p. 19
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OBJ: Nursing Process Step: Planning MSC: Physiological Integrity
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Which patient outcome is stated correctly?
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a. The child will administer his insulin injection before breakfast on 10/31.
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b. The child will accept the diagnosis of type 1 diabetes mellitus before discharge.
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c. The parents will understand how to determine the childs daily insulin dosage.
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d. The nurse will monitor blood glucose levels before meals and at bedtime.
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ANS: A FY
,The outcome is stated in client terms, with a measurable verb and a time frame for
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action. The verb accept is difficult to measure. The goal of accepting a diagnosis
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before hospital discharge isunrealistic. Outcomes should be stated in client terms.
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Y FY FY FY FY FY FY FY FY
Nursing actions are determined after outcomes are developed in the implementation
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phase of the nursing process.
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DIF: Cognitive Level: Application REF: p. 20
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OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment
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MULTIPLE RESPONSE FY
A nurse is reviewing the nursing care plan for a hospitalized child. Which
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statements arecollaborative problems? Select all that apply. FY F
Y FY FY FY FY FY
a. Risk for injury FY FY
b. Potential complication of seizure disorder FY FY FY FY
c. Altered nutrition: Less than body requirements FY FY FY FY FY
d. Fluid volume deficit FY FY
e. Potential complication of respiratory acidosis FY FY FY FY
ANS: B, E FY FY
In addition to nursing diagnoses, which describe problems that respond to
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independent nursing functions, nurses must also deal with problems that are beyond FY FY FY FY FY FY FY FY FY FY FY FY
the scope of independent nursingpractice. These are sometimes termed collaborative
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Y FY FY FY FY FY FY
problemsphysiological complications that usually occur in association with a FY FY FY FY FY FY FY FY FY
specific pathological condition or treatment. The potential complications of seizure
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,disorder and respiratory acidosis are physiological complications that will require
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physician collaboration to treat. Risk for injury, altered nutrition, and fluid volume
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deficit will respond to independent nursing functions.
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DIF: Cognitive Level: Application REF: p. 20
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OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment
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Which nursing activities do not meet the standard of care? Select all that apply.
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a. Failure to notify a physician about a childs worsening condition
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b. Calling the supervisor about staffing concerns
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c. Delegating assessment of a new admit to the Unlicensed Assistive FY FY FY FY FY FY FY FY FY FY
Personnel(UAP) F
Y
d. Asking the Unlicensed Assistive Personnel (UAP) to take vital signs
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e. Documenting that a physician was unavailable and the nursing FY FY FY FY FY FY FY FY FY
supervisor wasnotified FY F
Y
ANS: A, C FY FY
, A nurse who fails to notify a physician about a childs worsening condition and
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delegating theassessment of a new admit to a UAP do not meet the standard of
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care. Calling the supervisor about staffing concerns, asking the UAP to take vital
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signs, and documenting that a physiciancould not be reached and the nursing
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supervisor was notified all meet the standard of care.
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A nurse is reviewing changes in healthcare delivery and funding for pediatric
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populations.Which current trend in the pediatric setting should the nurse expect
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Y FY FY FY FY FY FY FY FY FY FY FY
to find?
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a. Increased hospitalization of children FY FY FY
b. Decreased number of uninsured children FY FY FY FY
c. An increase in ambulatory care
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d. Decreased use of managed care FY FY FY FY
ANS: C FY
One effect of managed care is that pediatric healthcare delivery has shifted
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dramatically from theacute care setting to the ambulatory setting. The number of
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Y FY FY FY FY FY FY FY FY FY FY
hospital beds being used has decreased as more care is provided in outpatient and
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home settings. The number of uninsured children in the United States continues to
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grow. One of the biggest changes in healthcare has been the growth of managed care.
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DIF: Cognitive Level: Comprehension REF: p. 3
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OBJ: Nursing Process Step: Planning MSC: Safe and Effective Care Environment
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