Which actions does the nurse need to take before determining the types of nursing
diagnoses that are applicable to a patient? (Select all that apply.)
a. Review the patient's past and present medical history.
b. Analyze the nursing assessment data to determine whether information is complete.
c. Outline an individualized plan of care to address each concern.
d. Consider potential complications to which the patient is susceptible.
e. Evaluate how the patient has responded to treatment.
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a. Review the patient's past and present medical history.
b. Analyze the nursing assessment data to determine whether information is
complete.
d. Consider potential complications to which the patient is susceptible.
An uncooperative 70-year-old male with right-sided paralysis from a recent
cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair.
,Which action indicates the best method to transfer this patient?
a. A two-person lift is performed, with one person on each side of the patient.
b. The patient is steadied under the arms and pivoted on his left leg.
c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP).
d. A stand assist lift is used with the help of another nurse.
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c. A full-body sling lift is used with the help of unlicensed assistive
personnel (UAP).
Which activity by the nurse best demonstrates part of the working phase of a patient
interview?
a. Summarizing previously discussed key topics
b. Including selected family members in care planning
c. Transferring care responsibilities to the home health nurse
d. Verifying the name by which a patient prefers to be addressed
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b. Including selected family members in care planning
When initiating a physical examination, which action should the nurse take first?
a. Review of the patient's prior medical records
b. Gather admission health history forms
c. Assess the patient's vital signs
d. Perform light and deep palpation for fluid
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, c. Assess the patient's vital signs
Which nursing diagnosis statements are appropriately written according to 2018-2020
NANDA-I format? (Select all that apply.)
a. Risk for Infection (ICNP) related to elevated temperature and white blood count
b. Readiness for Effective Family Process (ICNP) as evidenced by an expressed desire
for improved communication and mutual respect verbalized by family members
c. Impaired health maintenance (ICNP) related to inability to access care as
evidenced by failure to keep appointments, homebound status
d. Risk for Hemorrhaging (ICNP) as evidenced by prolonged clotting time
e. Chronic Pain (ICNP) related to osteoarthritis as manifested by verbalized
postoperative discomfort
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b. Readiness for Effective Family Process (ICNP) as evidenced by an
expressed desire for improved communication and mutual respect
verbalized by family members
c. Impaired health maintenance (ICNP) related to inability to access care as
evidenced by failure to keep appointments, homebound status
d. Risk for Hemorrhaging (ICNP) as evidenced by prolonged clotting time
What is the primary purpose of the nursing diagnosis?
a. Resolving patient confusion
b. Communicating patient needs
c. Meeting accreditation requirements
d. Articulating the nursing scope of practice
Give this one a try later!
diagnoses that are applicable to a patient? (Select all that apply.)
a. Review the patient's past and present medical history.
b. Analyze the nursing assessment data to determine whether information is complete.
c. Outline an individualized plan of care to address each concern.
d. Consider potential complications to which the patient is susceptible.
e. Evaluate how the patient has responded to treatment.
Give this one a try later!
a. Review the patient's past and present medical history.
b. Analyze the nursing assessment data to determine whether information is
complete.
d. Consider potential complications to which the patient is susceptible.
An uncooperative 70-year-old male with right-sided paralysis from a recent
cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair.
,Which action indicates the best method to transfer this patient?
a. A two-person lift is performed, with one person on each side of the patient.
b. The patient is steadied under the arms and pivoted on his left leg.
c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP).
d. A stand assist lift is used with the help of another nurse.
Give this one a try later!
c. A full-body sling lift is used with the help of unlicensed assistive
personnel (UAP).
Which activity by the nurse best demonstrates part of the working phase of a patient
interview?
a. Summarizing previously discussed key topics
b. Including selected family members in care planning
c. Transferring care responsibilities to the home health nurse
d. Verifying the name by which a patient prefers to be addressed
Give this one a try later!
b. Including selected family members in care planning
When initiating a physical examination, which action should the nurse take first?
a. Review of the patient's prior medical records
b. Gather admission health history forms
c. Assess the patient's vital signs
d. Perform light and deep palpation for fluid
Give this one a try later!
, c. Assess the patient's vital signs
Which nursing diagnosis statements are appropriately written according to 2018-2020
NANDA-I format? (Select all that apply.)
a. Risk for Infection (ICNP) related to elevated temperature and white blood count
b. Readiness for Effective Family Process (ICNP) as evidenced by an expressed desire
for improved communication and mutual respect verbalized by family members
c. Impaired health maintenance (ICNP) related to inability to access care as
evidenced by failure to keep appointments, homebound status
d. Risk for Hemorrhaging (ICNP) as evidenced by prolonged clotting time
e. Chronic Pain (ICNP) related to osteoarthritis as manifested by verbalized
postoperative discomfort
Give this one a try later!
b. Readiness for Effective Family Process (ICNP) as evidenced by an
expressed desire for improved communication and mutual respect
verbalized by family members
c. Impaired health maintenance (ICNP) related to inability to access care as
evidenced by failure to keep appointments, homebound status
d. Risk for Hemorrhaging (ICNP) as evidenced by prolonged clotting time
What is the primary purpose of the nursing diagnosis?
a. Resolving patient confusion
b. Communicating patient needs
c. Meeting accreditation requirements
d. Articulating the nursing scope of practice
Give this one a try later!
