Nursing documentation is guided by:
a. the Nursing process
b. the North American Nursing Diagnosis Association (NANDA) diagnoses.
c. Nursing Interventions Classification.
d. Nursing Outcomes Classification
ANS: A
Nursing documentation is guided by the five steps of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. Standardized nursing terminologies such as the North American Nursing Diagnosis Association-International (NANDA-I) nursing diagnoses, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) may be used in the documentation process.
You might also like to view...
A patient, age 26, has had a tubal insufflation (Rubin test) to ascertain whether her fallopian tubes are patent. She complains of pain in her right shoulder. Which response is most appropriate?
a. "Don't worry, that is a normal reaction." b. "I'll report the findings immediately to the head nurse." c. "That is a symptom that resulted from your position on the operating table." d. "That is from the carbon dioxide passing from the fallopian tubes into your abdomen."
A client has rapidly progressing ARDS. Which actions by the nurse can help the family during this crisis? (Select all that apply.)
a. Avoid disturbing them in the waiting room. b. Limit visiting time so the family does not fatigue. c. Provide frequent condition updates. d. Use clear communication.
The nurse is providing preoperative teaching to a patient scheduled for a subtotal thyroidectomy. What should the nurse include in these instructions?
1. Report sensations of tingling in toes, fingers, or lips. 2. Report signs of constipation. 3. Report the improvement of hoarseness. 4. Take aspirin before the surgery.
The nurse is planning care for a postpartum client. Which data in the client's history increase the risk for postpartum depression? Select all that apply
1. Type 1 diabetes mellitus (DM) 2. Bipolar disorder 3. Premenstural dysphoric disorder (PMDD) 4. Recent relocation to a new city 5. Family history of hypertension