Exam 6: Providing Patient-Centered Care Through the Nursing Process

Determine which example is true of measurability within the context of the nursing diagnosis.

In the assessment phase of the nursing process, there are several ways to collect data. Which statements reflect the need for more training? (Select all that apply.)

The nurse is charting on the patient who is status post-surgery for an abdominal abscess and notes: "Pt's temperature has not exceeded 37°C this shift." This is an example of a(n)

The nurse is planning care for an 82-year-old obese female patient with Alzheimer's dementia. The patient wanders, is unsteady on her feet, and is visually impaired. What should the nurse give priority to when developing the plan of care?

An example of an intervention independently initiated by the nurse is

While the nurse is taking the health history, the patient states, "My father and grandfather both had heart attacks and were unable to be very active afterward." How does the nurse interpret this? This statement is related to the functional health pattern of

Which of the following would be a priority nursing diagnosis for a 73-year-old male patient with heart failure?

An RN team leader has one LPN and one medical assistant assigned to the unit. Which patient would be most appropriate to assign to the LPN?

The nurse reviews assessment findings for assigned patients. Based on this information, which patient demands the nurse's immediate attention? The patient with

The nurse is using Gordon's 11 categories for data collection in performing a health assessment. Which of the following represents assessment of cognition?

Errors may occur with the use of data in formulating an appropriate nursing diagnosis. Based on what you know, which of the following represents the main source of errors in the nursing diagnosis process?

Which statement by the nurse illustrates how a RN's patient assessment differs from the LPNs patient assessment?

A patient admitted with a diagnosis of Alzheimer's disease is anxious and dehydrated, has reportedly not been eating, and has had a weight loss of 5 lb in 1 week. Which nursing diagnosis is a priority?

A patient with pneumonia has been using the incentive spirometer four times daily while awake during his 3-day hospitalization. How would the nurse explore the effectiveness of this intervention?

A nursing intervention directs the patient to be turned every 2 hours to prevent skin breakdown from immobility. Assessment findings on new reddened areas on the lateral aspects of the right knee and ankle are obtained. What is the most appropriate way for these findings to be used when the care plan is evaluated?

The nurse is attempting to take the history of a newly admitted 92-year-old patient but is unable to obtain the information because of the patient's cognitive status. The nurse should

Which of the following would be an expected outcome for a patient who is 12 hours status post hip replacement?

Which of the following is an example of a measurable outcome for the patient who has undergone a surgical procedure with a pain rating of 7 on a scale of 0 to 10?

The nurse is admitting a 64-year-old Hispanic male patient to the rehabilitation facility following surgical intervention for a broken hip. The nurse should first assess which of the following?

Which outcome statement is a properly written goal?