A goal specifies the expected behavior or response that indicates...
Correct Answer-Resolution of a nursing diagnosis or maintenance of a
health state.
(if the goal is not met, the problem is not solved)
Which of these selections is an etiology for Acute pain versus a defining
characteristic?
A. Complaint of pain as a 7 on a 0 to 10 scale
B. Disruption of tissue integrity
C. Dull headache
D. Discomfort while changing position Correct Answer-B. Disruption of
tissue integrity
(think PES sx vs. etiology)
,An 18-year-old woman in the emergency department with fever and
cough. The nurse obtains her vital signs, auscultates her lung sounds,
listens to her heart, sounds, determines her level of comfort, and collects
blood and sputum samples for analysis. Which stand of practice is
performed?
A. Diagnosis
B. Evaluation
C. Assessment
D. Implementation Correct Answer-C. assessment
One purpose of using standard formal nursing diagnoses in practice is to
A. Form a language that can be encoded only by nurses
B. Distinguish the nurse's role from the physician's role
C. Allow for the communication of patient needs to assistive personnel
D. Help nurses focus on the scope of medical practice. Correct Answer-
B. Distinguish the nurse's role from the physician's role
(think which is the most important)
Appropriate documentation of a pt who has not heard his test results
Correct Answer-"The pt stated that he felt frustrated by the lack of
information he received regarding his tests."
Avoid opinionated
I this the correct way to document?
,The patient appears to be upset with his nurse because he wants his test
results immediately. Correct Answer-No
evidence-based practice Correct Answer-implementing interventions
based on scientific rationale (not standardized care plans, tradition, or
court)
Before implementing an intervention, critical think to Correct Answer-
determine whether an intervention is appropriate for the given situation
(not to evaluate effectiveness, establish goals, or actively do something)
Evaluative measures regarding weight Correct Answer-Weight and food
diary review
Which is the most correct?
A. Patient walked up and down hallway with assistance, tolerated well.
B. Patient up, out of bed, walked down hallway and back to room,
tolerated well.
C. Patient walked 50 feet and back down hallway with assistance from
nurse. Spouse also accompanied patient during walk.
D. Patient walked 50 feet and back down hallway with assistance from
nurse. HR 88 and regular before exercise, 94 and regular following
exercise. Correct Answer-D. Distance (pt walked 50 ft) specific (down
hallway) what you did (with assistance from nurse). Vitals with value
and when taken (HR 88 and regular before exercise).
What are some of the defining characteristics of activity intolerance?
, A. Decreased oral intake and decreased oxygen saturation when
ambulating
B. Decreased oxygen saturation when ambulating and complaints of
shortness of breath
C. Complaints of shortness of breath when getting out of bed and a
productive cough.
D. Productive cough and decreased oral intake. Correct Answer-B.
Decreased o2 sat w/amb and c/o SOB (not productive cough, decreased
PO)
1st thing you do if someone asks to go to the bathroom for the first time
Correct Answer-review activity orders
T/F you must intervene if a student documented a medication given by
another student Correct Answer-T
T/F you must intervene if a student included the date and time of all
entries in the chart Correct Answer-F
T/F you must intervene if a student stood with his back against the wall
while documenting on the computer Correct Answer-F-this actually
helps maintain privacy
T/F you must intervene if a student signed all documentation
electronically Correct Answer-F
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