Which of the following assists the nurse in the identification of nursing diagnoses?

validated data

data clustering

subjective data

objective data

Answer and Explanation

The Correct Answer is B

A. Validated data: While accurate data is crucial, validated data alone does not form a nursing diagnosis.

B. Data clustering: Data clustering involves grouping related signs, symptoms, and risk factors to determine patterns that lead to a nursing diagnosis.

C. Subjective data: Subjective data (e.g., pain, nausea) is part of assessment but must be combined with objective data to establish a diagnosis.

D. Objective data: Objective data (e.g., lab results, physical exam findings) is important, but a nursing diagnosis requires a comprehensive approach, including data clustering.

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Correct Answer is C

Explanation

A. Ensure subjective documentation: JCAHO (Joint Commission on Accreditation of Healthcare Organizations) promotes objective documentation to ensure accuracy and reliability in patient care records.

B. Make sure that all nurses use the same charting system: JCAHO does not mandate a uniform charting system, as institutions may use different electronic health record (EHR) systems.

C. Ensure quality patient care: JCAHO’s primary role is to establish and enforce standards to improve patient safety and healthcare quality.

D. Make sure insurance companies get paid correctly: JCAHO’s focus is on patient care quality, not financial reimbursement.

A. signs B. objective cues C. symptoms D. observable data

Correct Answer is C

Explanation

A. Signs: Signs are objective findings (e.g., fever, rash), observed by the nurse.

B. Objective cues: Objective cues are measurable and observable, whereas subjective data is based on the patient’s self-report.

C. Symptoms: Symptoms (e.g., pain, nausea, dizziness) are subjective because they cannot be measured directly and are reported by the patient.

D. Observable data: Observable data includes measurable signs, making it objective, not subjective.

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Which of the following assists the nurse in the identification of nursing diagnoses?

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Naxlex Comprehensive Predictor Exams

JCAHO regulates standards of care to:

Correct Answer is C

Explanation

When discovering subjective data, recognize that they relate to:

Correct Answer is C

Explanation

The nurse is trying to decide what interventions will assist the patient with dyspnea to meet needs demonstrated by the patient. This phase of the nursing process is:

Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

When using the SOAP method of charting, S stands for subjective data which means:

To what does objective data refer when assessing a patient?

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

One benefit of computerized charting is that: