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Chapter 1: An Introduction to Evidence-Based Clinical Practice Guidelines
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MULTIPLE CHOICE gg
• What is the primary purpose of the nursing assessment?
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• Identifying underlying pathologic conditions gg gg gg
• Assisting the physician in identifying medical conditions
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• Determining the patients mental status gg gg gg gg
• Exploring patient responses to health problems gg gg gg gg gg
ANS: D gg
A nursing assessment is done to identify the patients
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response to health problems. During the nursing assessment phase, a
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comprehensive information base is developed through a physical
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examination, nursing history, medication history, and professional
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observation. Identifying underlying pathologic conditions and
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assisting the physician in identifying medical conditions is not part
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of the nursing process.
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Determining the patients mental status is one part of the nursing
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assessment, but it is not the primary purpose.
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DIF: Cognitive Level: Comprehension
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REF: dm 36 OBJ: 1 | 3 TOP:
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Nursing Process Step: Assessment gg gg gg
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
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• What is the basis of the NANDA I taxonomy?
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• Functional health patterns gg gg
• Human response patterns gg gg
• Basic human needs gg gg
• Pathophysiologic needs gg
ANS: B gg
The NANDA I taxonomy identifies human response patterns.
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Functional components of health patterns are limited to activity,
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fluid volume, nutrition, self care, and sensory perception.
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Basic human needs comprise less than merely health patterns.
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Pathophysiologic needs are not part of the scope of NANDA I.
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,DIF: Cognitive Level: Knowledge
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REF: pp. 37-38 OBJ: 5 TOP:
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Nursing Process Step: Diagnosis
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MSC: NCLEX Client Needs Category: Physiological Integrity
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• Which task is included in the assessment step of the nursing process?
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• Establishing patient goals/outcomes gg gg
• Implementing the nursing care plan (NCP) gg gg gg gg gg
• Measuring goal/outcome achievement gg gg
• Collecting and communicating data gg gg gg
ANS: D gg
Data are collected and communicated in the assessment phase of the
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nursing process. Establishing goals is the function of planning.
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Implementing the NCP is the function of implementation. Measuring
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outcome achievement is the function of evaluation.
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DIF: Cognitive Level: Comprehension
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REF: dm 36 OBJ: 2 | 3 TOP:
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Nursing Process Step: Assessment gg gg gg
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
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• Which statement regarding nursing diagnoses is accurate?
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• Nursing diagnoses remain the same for as long as the disease is present.
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• Nursing diagnoses are written to identify disease states.
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• Nursing diagnoses describe patient problems that nurses treat.
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• Nursing diagnoses identify causes related to illness.
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ANS: C gg
Diagnostic statements identify problems a nurse is independently able
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to treat within the scope of professional practice. Nursing diagnoses
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vary with the changing condition of the patient. The response
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patterns are unique to the patient and are not disease specific.
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Nursing diagnoses describe the patients human response pattern.
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DIF: Cognitive Level: Comprehension
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, REF: pp. 37-38 OBJ: 5 TOP: Nursing
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Process Step: Diagnosis
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MSC: NCLEX Client Needs Category: Physiological Integrity
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• What do the classification systems NIC and NOC provide?
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• Individualized data banks of treatments related to disease processes gg gg gg gg gg gg gg gg
• Standardized language for reporting and analyzing nursing care deliverygg gg gg gg gg gg gg gg
• A measure for cost containment within medical institutions
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• Specialized interventions for rare diseases gg gg gg gg
ANS: B gg
Nursing classification systems such as NIC and NOC are designed to
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provide a standardized language for reporting and analyzing nursing
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care delivery that is individualized for each patient. Standardized
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terminology assists practitioners in the implementation of the five
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phases of the nursing process. Classification systems are not
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related to disease process and are not used for financial purposes.
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Classification systems include interventions for all health conditions.
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DIF: Cognitive Level: gg gg
Knowledge REF: dm 34 OBJ: 11
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TOP: Nursing Process Step:
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Implementation
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MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
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• Which type of nursing diagnosis will be written when
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the patient exhibits factors that makes him or her
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susceptible to the development of a problem?
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• Actual diagnosis zz
• Risk diagnosis zz
• Possible diagnosis zz
• Wellness diagnosis gg
ANS: B gg
When patients have the potential or risk for a problem to develop,
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a risk diagnosis is written. These diagnoses are two part
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statements such as Risk for falls related to unsteady gait. An
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actual diagnosis consists of a NANDA diagnostic label,
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contributing factor (if known), and defining characteristics such as
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signs and symptoms. A possible nursing diagnosis
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