A nursing care plan consists of:
orders for diagnostic and therapeutic procedures such as laboratory tests or x-rays
laboratory and x-ray reports, pathology reports, and the medication record
nursing orders for individualized interventions to assist the patient to meet expected outcomes
the physician's history and physical examination, as well as medical diagnoses
The Correct Answer is C
A. Orders for diagnostic and therapeutic procedures such as laboratory tests or x-rays:
This refers to medical orders, which are instructions given by a physician for diagnostic tests or treatments. These orders are not part of the nursing care plan. Nurses execute these orders but do not create them.
B. Laboratory and x-ray reports, pathology reports, and the medication record:
These are patient records and reports. While nurses use this information to inform their care, the reports themselves are not the nursing care plan. Nurses analyze these reports to make informed decisions regarding patient care.
C. Nursing orders for individualized interventions to assist the patient to meet expected outcomes:
This is the correct choice. Nursing care plans involve identifying the patient's nursing diagnoses (health issues that nurses can address), setting specific and measurable outcomes, planning interventions tailored to the patient's needs, and evaluating the outcomes. It's a holistic approach designed to address the patient's unique health challenges.
D. The physician's history and physical examination, as well as medical diagnoses:
This refers to the medical diagnosis and assessment, which are critical for understanding the patient's overall health. While nurses consider this information, the nursing care plan specifically focuses on nursing interventions and care strategies, making it distinct from the medical diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maslow's hierarchy of needs:
This statement is true. Prioritizing patient problems is often based on Maslow's hierarchy of needs, which categorizes human needs from basic physiological requirements to higher-level psychological needs. Patients' immediate and essential needs, such as airway, breathing, and circulation, are prioritized over other needs based on this framework.
B. The nurse-to-nurse report:
This statement is incorrect. Nurse-to-nurse report is essential for continuity of care, but it is not the basis for prioritizing patient problems. Prioritization is based on the patient's immediate needs and safety concerns.
C. Nonspecific data collection:
This statement is incorrect. Prioritization is based on specific data collected during the assessment, including physiological measurements, symptoms, and patient history. Nonspecific data collection wouldn't provide the necessary information for effective prioritization.
D. Managerial influence:
This statement is incorrect. While managers might provide guidelines and policies, the direct care nurse at the bedside typically prioritizes patient problems based on clinical judgment, immediate needs, and the nursing process.
Correct Answer is D
Explanation
A. "Don't worry; this pain won't last forever."
This statement dismisses the patient's concerns and does not encourage open communication about pain. It does not address the patient's current pain experience or provide a basis for effective pain management.
B. "You look pretty comfortable. Are you having any pain?"
While this statement attempts to inquire about the patient's pain, it might not encourage the patient to open up about their pain experience. The patient might downplay their pain to appear strong or not to be a bother.
C. "Is this pain the same as the pain you had yesterday?"
This question is specific and might help in assessing the consistency and nature of the pain. However, it assumes the patient had pain yesterday and does not open the conversation effectively for the patient to express their pain experience freely.
D. "Tell me about the pain you've been having."
This statement is open-ended and encourages the patient to express their pain experience in their own words. It creates a comfortable environment for the patient to discuss their pain, allowing the nurse to gather valuable information about the pain's intensity, location, quality, and factors that aggravate or alleviate it. This approach is patient-centered and allows for a comprehensive pain assessment.
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