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 D

Explanation

A. The patient's friends: While family and friends can provide secondary information, they are not the primary source of assessment data.

B. Past medical records: Past records can provide valuable history, but they do not replace real-time data from the patient.

C. The patient's record: The medical record is a collection of past documentation but is not a source of new assessment data.

D. The patient: The patient is the primary source of assessment data, as they provide information about their symptoms, medical history, and concerns.

A. Incident reports must be recorded in the nurse's notes B. Institutions are only reimbursed for patient care that is documented C. Document only when not successful D. The patient record is a complete picture of individualized problems, treatments and responses to treatments

Correct Answer is ["B","D"]

Explanation

A. Incident reports must be recorded in the nurse's notes: Incident reports should not be recorded in the patient’s chart. They are used internally to improve patient safety and should be kept separate from the medical record.

B. Institutions are only reimbursed for patient care that is documented: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as documentation serves as proof that care was provided.

C. Document only when not successful: Documentation should be comprehensive, including both successful and unsuccessful interventions, to provide a full picture of patient care.

D. The patient record is a complete picture of individualized problems, treatments, and responses to treatments: A patient's medical record includes their health status, nursing interventions, and responses, making it a complete reference for continuity of care.

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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

The primary source of assessment information is:

Correct Answer is D

Explanation

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

Correct Answer is ["B","D"]

Explanation

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