QUESTIONS
Question 1
Select the statement that includes the correct elements to use when documenting a problem-based nursing diagnosis.
- Problem statement/as evidenced by
- Signs and symptoms/reasons for seeking care/goals of treatment
- Diagnosis label/related to statement/defining characteristics
- Subjective data/objective data/hypothesis
Question 2
The boxes below represent containers on a Care Focused Concept Map. Using the drop-down menu, indicate which step of the nursing process aligns with each container in the care focus concept map.
Monitoring the patient for side effects of prescribed medications aligns with the ___________ part of the nursing process.
Identifying client’s signs and symptoms aligns with the _______ part of the nursing process.
Describing desired outcomes needed to reach a goal aligns with __________ part of the nursing process.
Identifying a problem, risk, or health promotion need aligns with the __________ part of the nursing process.
Question 3
Attention to details, or cues, is key to successful patient care. It can also be a challenge. The video below will challenge your ability to see the details despite distractions.
As you watch, count the number of times the players in the white shirts pass the ball. Then select your response from the drop-down menu _____________.
Question 4
43-year-old male no previous medical history, no allergies, taking no medications, reports loss of smell and taste. Temperature 101.3 F, fatigue, and generalized muscle pain present when he awoke today. No symptoms noted prior to today. Works as a physician’s assistant in a private surgical practice. Has been treating patients through the current global health pandemic, following current guidelines to decrease transmission. Currently, wearing a mask and isolating from family. Referred for COVID-19 testing, advised to continue quarantine for 10 days after all symptoms have resolved, treat symptoms with OTC products, rest, hydration as tolerated, and seek immediate medication if symptoms worsen. Client voices concern related to continued exposure of wife and son to his illness, but is not able to afford to quarantine outside the apartment they share. They are also running out of personal protective equipment and hand sanitizer, adding to his concern. Referred to case manager for assistance locating PPE supplies for client and family. B. Scott. RN
Question 5
After reviewing the nurse’s notes and selecting the cues that require follow-up, the nurse now clusters the related cues to assist in identifying health promotion, risk for, or actual problems.
Note: Some cues may apply to both clusters.
Temperature 101.3F
Running out of personal protective equipment
Treating patients through the current global health pandemic
Not able to afford to quarantine outside the apartment
Voices concern related to continued exposure of wife and son
Loss of smell and taste
Generalized muscle pain
fatigue.
Question 6
After reviewing the nurse’s notes and selecting the cues, the nurse no selects a nursing diagnosis. Using a nursing diagnosis textbook, select the most appropriate diagnosis label and related to statement, based on Sami’s information.
Nursing Diagnosis: Risk for ____________ related _______________.
Nursing diagnosis: ____________ related to ______________ as evidenced by __________________.
Question 7
After reviewing the nurse’s notes and selecting the cues, the nurse no selects a nursing diagnosis. Using a nursing diagnosis textbook, select the most appropriate diagnosis label and related to statement, based on Sami’s information.
Which is the priority nursing diagnosis?
Question 8
Drag each item (taken from Sami’s Nursing Diagnosis and Plan of Care) to the correct location on the care Focused Concept Map.
After reviewing the nurse’s notes and selecting the cues, the nurse now selects a nursing diagnosis. Using a nursing diagnosis textbook. Select the most appropriate diagnosis label and related to statement, based on Sami’s information.
Nursing Dignosis
Expected Outcome
Interventions
Question 9
Review Mrs. Votaw’s electronic health record (EHR). Remember, the information will change as her case study unfolds across the following questions, just like an actual EHR, so you should check each tabbed section with each question.
Question 10
Select the most appropriate nursing diagnosis for Mrs. Votaw by selecting the words or phrases that complete the sentence below.
__________ related to __________ as evidenced by ______________ and _____________. R. Stem. RN
Question 11
Based on your knowledge of Mrs. Votaw’s current health response, use a nursing diagnosis text to select priority collaborative outcomes for the current nursing diagnosis. Select all that apply.
- Blood pressure less than 120/70.
- Decreased urine output.
- Lungs clear to auscultation
- Decreased chest pain
- O2 saturation greater than 95%
Question 12
Select the words or phrases in the sentences below to create SMART goals for MRs. Votaw based on the selected priority collaborative outcomes.
- ____________ on _____________ when ____________________ _____________.
- _______ __________________ ____________.
Question 13
Based on your knowledge of Mrs. Votaw’s current health response, use a nursing diagnosis text to match these interventions with the supporting evidence-based rationale.
- Assess lung sounds every 4 hours and as needed.
- Titrate oxygen to keep oxygen levels above 95%
- Allow periods of rest between activities.
Question 14
Based on the documentation, indicate if Mrs. Votaw met, partially met, or did not meet her expected outcomes.
- Oxygen saturation greater than 95% on room air when performing activities of daily living by discharge.
- Lung sounds clear in 24 hours.
Question 15
The home health nurse is seeing Mr. Votaw for the first time. During the interview, Mrs. Votaw asks what steps she can take to avoid future hospitalizations. Which diagnosis should the nurse select?
Nursing Diagnosis
Measurable Expected Outcomes
Question 16
Based on Mrs. Votaw’s newest nursing diagnosis and outcome, select appropriate interventions with matching rationale for her care.
Interventions #1 _________________ . Matching rationale __________________________.
Interventions #2 ___________________. Matching rationale ______________.
ANSWERS
Select the statement that includes the correct elements to use when documenting a problem-based nursing diagnosis.
- Problem statement/as evidenced by
- Signs and symptoms/reasons for seeking care/goals of treatment
- Diagnosis label/related to statement/defining characteristics
- Subjective data/objective data/hypothesis
Correct Answer: Diagnostic label/related to statement/defining characteristics.
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