1. A fact.
2. An inference.
3. A judgement.
4. An opinion.
1. Asses why the client is not ingesting the food provided.
2. Continue to leave the food at the bedside until the client is hungry enough to eat.
3. Notify the primary care provider that tube feeding may be indicated soon.
4. Believe the client is not really hungry.
1. Accepting the preferences of the other nurses since there are several of them.
2. Recognizing that the nurse must have reached a false conclusion.
3. Considering going to a higher authority than the manager for an explanation.
4. Continuing to query the manager until the nurse understands the explanation.
1. The research method.
2. The trial-and-error method.
4. The nursing process.
1. Reexamines the purpose for making the decision.
2. Consults the client and family members to determine their view of the criteria.
3. Identifies and considers various means for reaching the outcomes.
4. Determines the logical course of action should intervening problems arise.
1. Notify the primary care provider.
2. Obtain vital signs and oxygen saturation.
3. Request a chest x-ray.
4. Call the rapid response team.
2. Intellectual humility.
1. Creating environments that support critical thinking.
2. Tolerating dissonance and ambiguity.
4. Seeking situations where good thinking is practiced.
1. “I will get a dietary consultant to talk to you before next week.”
2. “What do you think is so difficult about following a low sodium diet?”
3. “At least you survived a heart attack and are able to return to work.”
4. “You may not need to follow a low sodium diet for as long as you think.”
2. Research process.
3. Trial and error.
4. Problem solving.
1. Identifying major problems or needs.
2. Organizing data in the client’s family history.
3. Establishing short-term and long-term goals.
4. Adminstering and antibiotic.
1. Purposes hypotheses.
2. Generates desired outcomes.
3. Reviews results of laboratory tests.
4. Documents care.
1. The nurse measures a weight loss of 10 pounds since the last clinic visit.
2. Spouse states the client has lost all appetite.
3. The nurse palpates edema in lower extremitites.
4. Client states severe pain when walking upstairs.
1. “What did the doctor tell you about your diagnosis?”
2. “Are you worried about how the diagnosis will affect you in the future?”
3. “Tell me about your reactions to this diagnosis.”
4. “How is your family responding to the diagnosis?”
1. Correlation of the data with other members of the health care team.
2. Demonstration of cost-effective care.
3. Utilization of creativity and intuition of creating a plan of care.
4. Collection of all necessary information for a thorough appraisal.
1. Establish a database of client responses to his or her health status.
2. Identify client strengths and problems.
3. Develop an individualized plan of care.
4. Implement care, prevent illness, and promote wellness.
1. Collects subjective data.
2. Applies a framework to the collected data.
3. Confirms data is complete and accurate.
4. Records data in the client record.
1. A focus on client needs.
2. It’s static nature.
3. An emphasis on physiology and illness.
4. It’s exclusive use by and with nurses.
1. When observing, the nurse uses only the visual sense.
2. Observing is done only when no other nursing interventions are being performed at the same time.
3. Data should be gathered as it occurs, rather than in any particular order.
4. Observed data should be interpreted in relation to other sources of collected data.
1. Keep the lighting dimmed so as not to stress the client’s eyes.
2. Ensure that no one can overhear the interview conversation.
3. Stand near the client’s head while he or she is in the bed or chair.
4. Keep approximately 3 feet from the client during the interview.
5. Use a standard form to be sure all relevant data are covered in the interview.
1. Assess the client’s needs.
2. Delineate the client’s problems and strengths.
3. Determine which interventions are most likely to succeed.
4. Estimate the cost of several different approaches.
1. Excess fluid volume.
2. Decreased venous return.
1. Risk for Caregiver Role Strain related to unpredictable illness course.
2. Risk for Falls related to tendency to collapse when having difficulty breathing.
3. Impaired Communication related to stroke.
4. Sleep Deprivation secondary to fatigue and a noisy environment.
1. Decreases the cost of health care.
2. Improves communication between nurse and client.
3. Helps the nurse focus on health and wellness elements.
4. Standardizes organization of client data.
1. If both medical and nursing intervention are required to treat the problem.
2. When independent nursing actions can be utilized to treat the problem.
3. In cases where nursing intervention are the primary actions required to treat the problem.
4. When no medical diagnosis (disease) can be determined.
1. A risk nursing diagnosis.
2. A wellness nursing diagnosis.
3. A health promotion nursing diagnosis.
4. An actual nursing diagnosis.
1. The original taxonomy has proven to be adequate in scope.
2. The organizing framework of the taxonomy is based on the work of Florence Nightingale.
3. More research is needed to validate and refine the diagnostic labels.
4. New diagnostic labels are approved by means of a vote of registered nurses.
1. The client has moved partway toward a set goal (e/g/, weight loss).
2. The client’s vision is within normal range only when wearing glasses.
3. A child is able to control bladder and bowels at age 18 months.
4. A woman widowed recently states she is “unable to cry.”
5. A 16 year old high school student reports spending 6 hours doing homework five nights per week.
1. Hospital policies.
2. Standardized care plans.
3. Orthopedic protocols.
4. Standards of care.
4. Potential for wound infection
1. Turn in bed q2h.
2. Report the importance of applying lotion to dry skin daily.
3. Have intact skin during hospitalization.
4. Use a pressure-reducing mattress.
1. Action verb
1. Establish goals/outcomes.
2. Write the care plan.
3. Set priorities.
4. Choose interventions.
1. No individualization is needed.
2. The nurse chooses from a list of interventions.
3. They are much shorter than nurse-authored care plans.
4. They have been approved by accrediting agencies.
1. There is no standard against which to compare outcomes.
2. The nursing diagnoses cannot be prioritized.
3. Only dependent nursing interventions can be used.
4. It is difficult to determine which nursing interventions can be delegated.
1. Do not require customization.
2. Address several nursing diagnoses.
3. Are broad statements of desired end points.
4. Reflect both the nurse’s and the client’s values.
1. Actions should address the etiology of the nursing diagnosis.
2. Always select independent interventions when possible.
3. There is one best intervention for each goal/outcome.
4. Interventions should be “doing.” not just “monitoring.”
1. Carrying out nurses interventions.
2. Determining the need for assistance.
3. Reassessing the client.
4. Documenting interventions.
1. When the activity is routine (e.g., raising the bed rails).
2. When the activity occurs at regular intervals (e.g., turning the client in bed).
3. When the activity is to be carried out immediately (e.g., a stat medication).
4. It is never acceptable.
1. Desired outcomes have been met.
2. Nursing activites were carried out.
3. Nursing activities were effective.
4. Client’s condition has changed.
1. Delete the diagnosis since the problem has not occured.
2. Keep the diagnosis since the risk factors are still present.
3. Modify the nursing diagnosis to Impaired Mobility.
4. Demote the nursing diagnosis to a lower priority.
1. Structure evaluation
2. Process evaluation
3. Outcome evaluation
1. The findings from the assessing phase are reconfirmed in the implementing phase.
2. After implementing, the nurse moves to the diagnosing phase.
3. The nurse’s need for involvement of other health care team members in implementing occurs during the planning phase.
4. Once all interventions can be completed, evaluating can begin.
1. No interventions should be carried out without the nurse having clear rationales.
2. Always follow the primary care provider’s orders exactly, without variation.
3. Encourage all clients to be as independent as desired and allow the nurse to perform care for them.
4. When possible, give the client options on how the interventions will be implemented.
5. Each intervention should be accompanied by client teaching.
1. Goal achievement must be written as either completely met or unmet.
2. Data related to expected outcomes must be collected.
3. If the outcome was achieved, conclude that the plan was effective.
4. After determining that the outcome was not met, start over with a new nursing care plan.
1. Focus is on individual outcomes.
2. Evaluates organizational structures.
3. Aims to confirm that quality exists.
4. Plans corrective actions for problems.