NANDA Dx
Which NANDA diagnosis is most appropriate for a patient experiencing difficulty breathing due to asthma?
1. Ineffective Airway Clearance
2. Impaired Gas Exchange
3. Activity Intolerance
4. Risk for Infection
1. Ineffective Airway Clearance
The most appropriate NANDA diagnosis for a patient with asthma and difficulty breathing is 'Ineffective Airway Clearance,' as asthma often involves mucus buildup and airway constriction.
What does 'related to' in a nursing care plan specify?
1. The patient's medical diagnosis
2. The underlying cause or contributing factor of the nursing diagnosis
3. The interventions required to address the problem
4. The expected outcome of the care plan
2. The underlying cause or contributing factor of the nursing diagnosis
'Related to' specifies the underlying cause or contributing factor of the nursing diagnosis, helping to identify the root issue that needs to be addressed.
What is the primary purpose of setting goals in a nursing care plan?
1. To document the patient's medical history
2. To provide a timeline for interventions
3. To establish measurable outcomes for evaluating progress
4. To determine the patient's diagnosis
3. To establish measurable outcomes for evaluating progress
Goals in a nursing care plan establish measurable outcomes that guide interventions and help evaluate the patient's progress toward resolving the identified problem.
Which action verb is most appropriate for creating an attainable goal?
1. Consider
2. Understand
3. Demonstrate
4. Believe
3. Demonstrate
Action verbs like 'Demonstrate' are appropriate for attainable goals because they describe specific actions that can be performed and evaluated. Verbs like 'Consider', 'Understand', or 'Believe' are vague and not actionable.
Which intervention is most appropriate for a patient with impaired skin integrity?
1. Administer pain medication as prescribed.
2. Apply a moisture barrier cream to affected areas.
3. Encourage the patient to drink more fluids.
4. Provide education on diabetes management.
2. Apply a moisture barrier cream to affected areas.
Moisture barrier cream is an important part of maintaining good skin integrity
Which NANDA diagnosis is most appropriate for a patient with a pressure ulcer?
1. Impaired Skin Integrity
2. Risk for Infection
3. Chronic Pain
4. Deficient Knowledge
1. Impaired Skin Integrity
The most appropriate NANDA diagnosis for a patient with a pressure ulcer is 'Impaired Skin Integrity,' as it directly addresses the physical condition of the skin.
Which of the following is an example of 'as evidenced by' in a nursing care plan?
1. Patient's medical history of diabetes
2. Patient's verbal report of pain rated 8/10
3. Patient's goal to walk 10 meters without assistance
4. Patient's prescribed medication regimen
2. Patient's verbal report of pain rated 8/10
'As evidenced by' refers to the observable signs or symptoms supporting the nursing diagnosis. A verbal report of pain rated 8/10 is an example of such evidence.
Which of the following is an example of a short-term goal in a nursing care plan?
1. Patient will maintain a healthy weight within 6 months.
2. Patient will verbalize pain relief within 1 hour after medication administration.
3. Patient will achieve improved mobility within 3 weeks.
4. Patient will demonstrate proper wound care techniques within 2 months.
2. Patient will verbalize pain relief within 1 hour after medication administration.
A short-term goal is typically achievable within hours or days. Verbalizing pain relief within 1 hour after medication administration is an example of a short-term goal.
Which of the following is an example of a measurable goal for a patient with diabetes?
1. Patient will verbalize understanding of the importance of maintaining blood glucose levels below 180 mg/dL
2. Patient will believe their blood glucose levels are improving.
3. Patient will recover fully from diabetes within one month.
4. Patient will feel better soon.
1. Patient will verbalize understanding of the importance of maintaining blood glucose levels below 180 mg/dL
This answer includes measurable elements
Evaluation components. Choose all that apply:
1. 'Met', 'Not met', or 'Partially met' must be included
2. Look at the goal when providing evidence for the evaluation
3. Both short-term and long-term goals must be evaluated
4. The goal does not have to be met for the care plan to be met
1. 'Met', 'Not met', or 'Partially met' must be included
2. Look at the goal when providing evidence for the evaluation
4. The goal does not have to be met for the care plan to be valid
Only the short-term goal must be evaluated
Which NANDA diagnosis is appropriate for a patient experiencing social isolation?
1. Impaired Social Interaction
2. Risk for Loneliness
3. Ineffective Coping
4. Deficient Knowledge
1. Impaired Social Interaction
The most appropriate NANDA diagnosis for a patient experiencing social isolation is 'Impaired Social Interaction,' as it directly addresses difficulties in engaging with others.
What is the role of evaluation in a nursing care plan?
1. To identify the patient's primary diagnosis
2. To determine the effectiveness of interventions and progress toward goals
3. To document the patient's medical history
4. To prescribe medications for the patient
2. To determine the effectiveness of interventions and progress toward goals
Evaluation assesses the effectiveness of interventions and determines whether the patient is progressing toward the established goals, allowing for adjustments to the care plan if needed.
Which of the following is an example of a measurable goal in a nursing care plan?
1. Patient will feel better soon.
2. Patient will walk 20 meters with assistance within 3 days.
3. Patient will improve mobility over time.
4. Patient will recover fully.
2. Patient will walk 20 meters with assistance within 3 days.
A measurable goal specifies a clear, quantifiable outcome. Walking 20 meters with assistance within 3 days is an example of a measurable goal.
Which of the following is an example of an attainable goal for a patient with hypertension?
1. Patient will believe their blood pressure is improving.
2. Patient will demonstrate the ability to measure their blood pressure using a home monitor by the end of the day.
3. Patient will recover fully from hypertension within one week.
4. Patient will consider reducing salt intake in their diet.
2. Patient will demonstrate the ability to measure their blood pressure using a home monitor by the end of the day.
An attainable goal uses action verbs and specifies a realistic task that the patient can accomplish. 'Patient will demonstrate the ability to measure their blood pressure using a home monitor by the end of the day' is attainable because it involves a specific, actionable task that can be achieved within the given timeframe.
What are examples of interventions that can be delegated by the nurse? Select all that apply
1. Taking vital signs
2. Ambulating a patient
3. Suggesting a Psych consult
4. Teaching the patient how to self-administer insulin shots
4. Teaching the patient how to self-administer insulin shots
Only the nurse can provide education
Which NANDA diagnosis is appropriate for a patient with a high risk of falling? Pick all that apply.
1. Impaired Physical Mobility
2. Activity Intolerance
3. Chronic Pain
4. Knowledge deficit
1. Impaired Physical Mobility
2. Activity Intolerance
These NANDA diagnoses for a patient at high risk of falling address the potential harm associated with falls.
What does 'as evidenced by' help to identify in a nursing care plan?
1. The patient's medical diagnosis
2. Observable signs and symptoms supporting the nursing diagnosis
3. The interventions required to address the problem
4. The expected outcome of the care plan
2. Observable signs and symptoms supporting the nursing diagnosis
'As evidenced by' identifies observable signs and symptoms that support the nursing diagnosis, providing evidence for the identified problem.
Which of the following is an example of a long-term goal in a nursing care plan?
1. Patient will verbalize pain relief within 1 hour.
2. Patient will achieve improved mobility within the next week.
3. Patient will maintain a healthy weight within 6 months.
4. Patient will demonstrate proper wound care techniques
3. Patient will maintain a healthy weight within 6 months.
Long-term goals should extend to a longer timeline. Number 4 does not include a time frame
Which of the following is an example of a measurable goal?
1. Patient will believe in the importance of exercise.
2. Patient will consider starting an exercise routine.
3. Patient will be satisfied with their progress.
4. Patient will verbalize 3 benefits of an exercise program.
4. The patient will verbalize 3 benefits of an exercise program.
A measurable goal uses parameters that can be evaluated. 'The patient will verbalize 3 benefits of an exercise program.' is measurable, while 'believe', 'be satisfied', and 'consider' are not measurable.
To whom can the RN delegate tasks? Choose all that apply.
1. PCT/CNA
2. MD
3. Dietary Department
4. Physical Therapy
1. PCT/CNA
2. MD
3. Dietary Department
4. Physical Therapy
The RN can delegate to other team member as long as the task is within their scope of practice.
Which NANDA diagnosis is appropriate for a patient experiencing acute pain?
1. Chronic Pain
2. Self-care deficit
3. Activity intolerance
4. Impaired Comfort
4. Impaired Comfort
The most appropriate NANDA diagnosis for a patient experiencing acute pain is Impaired Comfort as it directly addresses the immediate and severe discomfort.
What's the only goal that needs to be evaluated in the nursing care plan?
1. Long-term goal
2. Short-term goal
2. Short-term goal
You must include a long-term goal were indicated on your care plan, but you only need to evaluate the short-term goal
Which of the following is a properly worded evaluation statement
1. STG not met - pt did not have a bowel movement today
2. Pt will verbalize having a bowel movement
3. Encourage pt to walk in the hall
4. Pt stated he has not a bowel movement in 3 days
1. STG not met - pt did not have a bowel movement today
This includes information about the status of the goal and the evidence
Which of the following is an example of a realistic goal?
1. Patient will lose 10 lbs by the end of the week.
2. Patient will list 3 low-carb foods to incorporate into their diet.
3. Patient will fully recover from surgery within 2 days.
4. Patient will walk 1 mile without assistance within 2hrs post right knee arthroplasy.
2. Patient will list 3 low-carb foods to incorporate into their diet.
The other alternatives are not likely to happen within the stated timelines
Medical diagnoses can be used in nursing care plans.
1. True
2. False
2. False
Medical diagnoses identify the disease or condition, while nursing diagnoses focus on the patient's response to that condition or the potential for a response