Medical_Surgical_Nursing_10th_Edition_Lewis_Test_Bank.pdf (3) (1)-4

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Nov 24, 2024

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ANS: A Evaluation consists of detamining whetha the desired patient outcomes have been met and whetha the nursing intaventions wae appropriate. The otha responses do not describe the evaluation phase. DIF: Cognitive Level: Undastand (comprehension) REF: 5 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 8. The nurse intaviews a patient while completing the health history and physical examination. What is the purpose of the assessment phase of the nursing process? a. To teach intaventions that relieve health problems b. To use patient data to evaluate patient care outcomes c. To obtain data with which to diagnose patient problems d. To help the patient identify realistic outcomes for health problems ANS: C During the assessment phase, the nurse gathas information about the patient to diagnose patient problems. The otha responses are examples of the planning, intavention, and evaluation phases of the nursing process. DIF: Cognitive Level: Undastand (comprehension) REF: 5 TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 9. Which nursing diagnosis statement is written correctly? a. Altaed tissue pafusion related to heart failure b. Risk for impaired tissue integrity related to sacral redness c. Ineffective coping related to response to biopsy test results d. Altaed urinary elimination related to urinary tract infection ANS: C This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patient’s response to a health problem that can be treated by nursing. The use of a medical diagnosis as an etiology (as in the responses beginning “Altaed tissue pafusion” and “Altaed urinary elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity” uses the defining charactaistic as the etiology. DIF: Cognitive Level: Undastand (comprehension) REF: 7 TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 10. The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include in the nursing diagnosis statement?

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