1. All of the following would be considered subjective data, EXCEPT:
a. Patient-reported health history
b. Patient-reported signs and symptoms of their
... [Show More] illness
c. Financial barriers reported by the patient’s caregiver
d. Vital signs obtained from the medical record
ANS: D
Subjective data is based on what patients or family members communicate to the nurse. Patient- reported health history, signs and symptoms, and caregiver reported financial barriers would be considered subjective data. Vital signs obtained from the medical record would be considered objective data.
DIF: Cognitive Level: Understanding (Comprehension) TOP: Nursing Process: Planning MSC: NCLEX: Management of Client Care
2. The nurse is using data collected to define a set of interventions to achieve the most desirable outcomes. Which of the following steps is the nurse applying?
a. Recognizing cues (assessment)
b. Analyze cues & prioritize hypothesis (analysis)
c. Generate solutions (planning)
d. Take action (nursing interventions)
ANS: C
When generating solutions (planning), the nurse identifies expected outcomes and uses the patient’s problem(s) to define a set of interventions to achieve the most desirable outcomes. Recognizing cues (assessment) involves the gathering of cues (information) from the patient about their health and lifestyle practices, which are important facts that aid the nurse in making clinical care decisions. Prioritizing hypothesis is used to organize and rank the patient problem(s) identified. Finally, taking action involves implementation of nursing interventions to accomplish the expected outcomes.
DIF: Cognitive Level: Understanding (Comprehension) TOP: Nursing Process: Nursing Intervention
MSC: NCLEX: Management of Client Care
3. A 5-year-old child with type 1 diabetes mellitus has had repeated hospitalizations for episodes of hyperglycemia. The parents tell the nurse that they can’t keep track of everything that has to be done to care for their child. The nurse reviews medications, diet, and symptom management with the parents and draws up a daily checklist for the family to use. These activities are completed in which step of the nursing process?
a. Recognizing cues (assessment)
b. Analyze cues & prioritize hypothesis (analysis)
c. Generate solutions (planning)
d. Take action (nursing interventions)
ANS: D
Taking action through nursing interventions is where the nurse provides patient health teaching, drug administration [Show Less]