Thankoon is a nursing student who is assigned to Ms. Trembly. Ms. Trembly is a 72-
year-old Caucasian female who is admitted to the medical-surgical unit for
management of hypotension secondary to heart disease.
Ms. Trembly's blood pressure on admission is 82/54 mm Hg; but several hours later
her blood pressure has dropped to 76/50 mm Hg. She complains of nausea, fatigue,
and blurred vision.
1. Thankoon revises the plan of care for Ms. Trembly based on her decrease in blood
pressure and complaint of nausea, fatigue, and blurred vision. Revising Ms. Trembly's
care plan involves four steps. Rank in order the following steps.
A. Choose the method of evaluation for determining achievement of Ms. Trembly's
outcomes.
,B. Revise the specific interventions that correspond to Ms. Trembly's new nursing
diagnoses and goals.
C. Revise data in the assessment column to reflect Ms. Trembly's current status.
D. Revise Ms. Trembly's nursing diagnoses.
Give this one a try later!
Answer: C, D, B, A
Rationale: Modification of an existing written care plan includes four steps:
revising data in the assessment column to reflect the patient's current
status; revising the nursing diagnoses; revising specific interventions that
correspond to the new nursing diagnoses and goals; and choosing the
method of evaluation for determining whether you achieved patient
outcomes.
Nigel is a nursing student assigned to Mr. Hannigan, a 72-year- old Caucasian with a
diagnosis of pneumonia who is admitted to the medical-surgical unit. Mr. Hannigan is
a one-pack-per-day smoker who experiences chronic problems with bronchitis and
pneumonia as a result of his smoking. Nigel's immediate tasks are to complete an
admission history and physical examination and design a care plan for Mr. Hannigan.
1. Which of the following of Mr. Hannigan's assessment findings can Nigel group
together to formulate a data cluster? (Select all that apply.)
A. Respirations 32 breaths/min
B. Crackles in right and left lung bases
C. Pain at incision site
D. Shortness of breath with ambulation
E. Hematuria
Give this one a try later!
Answer: A, B, D
Rationale: A data cluster is a set of signs or symptoms gathered during
assessment that are grouped together in a logical way. Respiratory rate,
lung sounds, and shortness of breath are respiratory assessment findings
, that may be grouped together to manage a respiratory problem. Pain at the
incision site and hematuria aren't directly related to respiratory issues.
A nurse in a community health clinic has been caring for a young female teenager
with Type 1 diabetes mellitus for several months. The expected outcome for this
patient is to achieve self-management of insulin administration by discharge. Identify
appropriate evaluative measures for self-management for this patient. (Select all that
apply.)
1. Quality of life
2. Patient satisfaction
3. Clinic follow-up visits
4. Adherence to self-administration of insulin
5. Description of side effects of medications
6. Patient report of blood glucose level
Give this one a try later!
Answer: 1, 3, 4, 5.
Quality of life is a standard measure for patients with a chronic disease such
as diabetes mellitus. Adherence to medication administration,
demonstrated psychomotor skill (e.g., self-injection), and adherence to
medical follow-up visits are common measures of health behavior. Patient
satisfaction is not a measure as to whether the patient is managing her
diabetes. Description of side effects measures a level of knowledge
relevant to the patient's ability to self-manage diabetes. The patient's
selfreport of blood glucose level is a physiological indicator that does not
reflect self-management behavior
Review the following nursing diagnoses and identify the diagnoses that are stated
correctly. (Select all that apply.)
1. Offer frequent skin care because of Impaired Skin Integrity
, 2. Risk for Infection
3. Chronic Pain related to osteoarthritis evidenced by reduced hip range of motion
4. Activity Intolerance related to physical deconditioning evidenced by exertional
dyspnea
5. Lack of Knowledge related to laser surgery
Give this one a try later!
Answer: 2, 4.
Option 2 is a "risk for" diagnosis and does not have related factors.
Option 4 has related factors and an assessment finding that allows a nurse
to select etiology-specific interventions. Option 1 identifies a nursing
intervention instead of a problem.
Option 3 has a related factor of a medical diagnosis, which a nurse cannot
treat directly.
Option 5 describes a treatment procedure and not the patient's response
to the procedure.
Nigel is a nursing student assigned to Mr. Hannigan, a 72-year- old Caucasian with a
diagnosis of pneumonia who is admitted to the medical-surgical unit. Mr. Hannigan is
a one-pack-per-day smoker who experiences chronic problems with bronchitis and
pneumonia as a result of his smoking. Nigel's immediate tasks are to complete an
admission history and physical examination and design a care plan for Mr. Hannigan.
2. Nigel develops nursing diagnoses for Mr. Hannigan's care plan. Impaired gas
exchange is a ______ nursing diagnosis for pneumonia.
Give this one a try later!
year-old Caucasian female who is admitted to the medical-surgical unit for
management of hypotension secondary to heart disease.
Ms. Trembly's blood pressure on admission is 82/54 mm Hg; but several hours later
her blood pressure has dropped to 76/50 mm Hg. She complains of nausea, fatigue,
and blurred vision.
1. Thankoon revises the plan of care for Ms. Trembly based on her decrease in blood
pressure and complaint of nausea, fatigue, and blurred vision. Revising Ms. Trembly's
care plan involves four steps. Rank in order the following steps.
A. Choose the method of evaluation for determining achievement of Ms. Trembly's
outcomes.
,B. Revise the specific interventions that correspond to Ms. Trembly's new nursing
diagnoses and goals.
C. Revise data in the assessment column to reflect Ms. Trembly's current status.
D. Revise Ms. Trembly's nursing diagnoses.
Give this one a try later!
Answer: C, D, B, A
Rationale: Modification of an existing written care plan includes four steps:
revising data in the assessment column to reflect the patient's current
status; revising the nursing diagnoses; revising specific interventions that
correspond to the new nursing diagnoses and goals; and choosing the
method of evaluation for determining whether you achieved patient
outcomes.
Nigel is a nursing student assigned to Mr. Hannigan, a 72-year- old Caucasian with a
diagnosis of pneumonia who is admitted to the medical-surgical unit. Mr. Hannigan is
a one-pack-per-day smoker who experiences chronic problems with bronchitis and
pneumonia as a result of his smoking. Nigel's immediate tasks are to complete an
admission history and physical examination and design a care plan for Mr. Hannigan.
1. Which of the following of Mr. Hannigan's assessment findings can Nigel group
together to formulate a data cluster? (Select all that apply.)
A. Respirations 32 breaths/min
B. Crackles in right and left lung bases
C. Pain at incision site
D. Shortness of breath with ambulation
E. Hematuria
Give this one a try later!
Answer: A, B, D
Rationale: A data cluster is a set of signs or symptoms gathered during
assessment that are grouped together in a logical way. Respiratory rate,
lung sounds, and shortness of breath are respiratory assessment findings
, that may be grouped together to manage a respiratory problem. Pain at the
incision site and hematuria aren't directly related to respiratory issues.
A nurse in a community health clinic has been caring for a young female teenager
with Type 1 diabetes mellitus for several months. The expected outcome for this
patient is to achieve self-management of insulin administration by discharge. Identify
appropriate evaluative measures for self-management for this patient. (Select all that
apply.)
1. Quality of life
2. Patient satisfaction
3. Clinic follow-up visits
4. Adherence to self-administration of insulin
5. Description of side effects of medications
6. Patient report of blood glucose level
Give this one a try later!
Answer: 1, 3, 4, 5.
Quality of life is a standard measure for patients with a chronic disease such
as diabetes mellitus. Adherence to medication administration,
demonstrated psychomotor skill (e.g., self-injection), and adherence to
medical follow-up visits are common measures of health behavior. Patient
satisfaction is not a measure as to whether the patient is managing her
diabetes. Description of side effects measures a level of knowledge
relevant to the patient's ability to self-manage diabetes. The patient's
selfreport of blood glucose level is a physiological indicator that does not
reflect self-management behavior
Review the following nursing diagnoses and identify the diagnoses that are stated
correctly. (Select all that apply.)
1. Offer frequent skin care because of Impaired Skin Integrity
, 2. Risk for Infection
3. Chronic Pain related to osteoarthritis evidenced by reduced hip range of motion
4. Activity Intolerance related to physical deconditioning evidenced by exertional
dyspnea
5. Lack of Knowledge related to laser surgery
Give this one a try later!
Answer: 2, 4.
Option 2 is a "risk for" diagnosis and does not have related factors.
Option 4 has related factors and an assessment finding that allows a nurse
to select etiology-specific interventions. Option 1 identifies a nursing
intervention instead of a problem.
Option 3 has a related factor of a medical diagnosis, which a nurse cannot
treat directly.
Option 5 describes a treatment procedure and not the patient's response
to the procedure.
Nigel is a nursing student assigned to Mr. Hannigan, a 72-year- old Caucasian with a
diagnosis of pneumonia who is admitted to the medical-surgical unit. Mr. Hannigan is
a one-pack-per-day smoker who experiences chronic problems with bronchitis and
pneumonia as a result of his smoking. Nigel's immediate tasks are to complete an
admission history and physical examination and design a care plan for Mr. Hannigan.
2. Nigel develops nursing diagnoses for Mr. Hannigan's care plan. Impaired gas
exchange is a ______ nursing diagnosis for pneumonia.
Give this one a try later!
