Nursing Diagnosis

Question 1

What describes a patient’s response to a medical illness or disease process?

Answer 1

Nursing diagnosis

Question 2

What must be done each time an ECO is not met?

Answer 2

Revision

Question 3

An example of this type of assessment is when a nurse looks at a surgical incision for redness and asks about any pain (but does not complete a head-to-toe assessment)

Answer 3

Focused assessment

Question 4

List the components of a SMART expected client outcome

Answer 4

S-Specific
M-Measurable
A-Attainable
R-Realistic
T-Time oriented

Question 5

The nurse should check with this person before activating a nursing diagnosis for a care plan

Answer 5

The patient

Question 6

This describes how assessment and evaluation are different

Answer 6

Time (assessment is before)

Question 7

What kind of data is when a patient says “there is a sharp pain radiating down my arm?”

Answer 7

Subjective data

Question 8

Type & source of data: Temperature 103.1 (obtained with thermometer)

Answer 8

Secondary objective

Question 9

An example of this type of ECO is: “Patient will walk 25 feet by the end of shift today.”

Answer 9

Short term goal

Question 10

Identify the priority problem and explain how you decided the priority: impaired tissue perfusion vs risk for falls.

Answer 10

Impaired renal perfusion (actual problem) and by Maslow’s Hierarchy of Needs and ABCs.

Question 11

An example of this type of knowledge is when a nurse uses a Kangaroo pump to administer enteral tube feeding.

Answer 11

Practical knowledge

Question 12

Within the nursing diagnosis, this is where the student nurse will look when determining the most relevant interventions for a plan of care?

Answer 12

Etiology

Question 13

Where the nurses should look to evaluate once it is determined the care plan needs a revision

Answer 13

The nursing process (Each step)

Question 14

The nurse uses this information to select a nursing diagnosis (ex: fever, thick wound drainage, elevated WBC)

Answer 14

Clustered data cues

Question 15

List the 5 right of delegation

Answer 15

1. Right task
2. Right person
3. Right supervision
4. Right circumstance
5. Right communication

Question 16

This type of nursing diagnosis only has a two-part statement, the problem and the etiology.

Answer 16

Potential nursing diagnosis “risk for”

Question 17

An example of this is: the nurse administers medication ordered by a physician

Answer 17

Dependent intervention

Question 18

This organization created a taxonomy of terms to describe a universal nursing language describing nursing terms

Answer 18

NANDA international

Question 19

This term describes ischemia in the following statement: “impaired skin integrity related to ischemia as evidenced by redness and visible subcutaneous tissue.”

Answer 19

Etiology

Question 20

An example of this is: the nurse coordinates a nutrition consult with a the dietician

Answer 20

Interdependent intervention (collaborative)

Question 21

Which is the better ECO & explain why: Patient will eat 50% of lunch today vs nurse will answer call lights in a timely manner within 1 hour.

Answer 21

Patient will eat 50% of lunch today— patient centered

Question 22

ECO: patient will perform incentive spirometry to 2500 ml
Action: Pt performed incentive spirometry to 2000 ml
How should the nurse document this outcome and what should be done about it?

Answer 22

Not met-Revise the care plan

Question 23

This is where the nurse should refer to when planning the expected client outcome (ECO)

Answer 23

NANDA (patient problem)

Question 24

Identify how assessment is related to implementation

Answer 24

The effectiveness of the intervention; assessing the impact of ECO

Question 25

An example of this type of assessment is when a nurse re-evaluates a patient’s pain levels after providing pain medication to the patient

Answer 25

Intermittent assessment