Which of the following can be used to document the elements of the nursing process within the care plan?
1. The Omaha System
2. The PeriOperative Nursing Data Set
3. Personal health record
4. NANDA-I
4
Rationale: NANDA-I is used to document nursing diagnoses within all settings and across the care continuum. The coding system can be used within the EHR. NANDA-I has been linked to the NIC interventions and NOC outcomes.
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A child diagnosed with depression is given the nursing diagnosis of situational low self-esteem. Which statement by the child indicates that a short-term goal has been met?
A. "I have to sleep a lot when I feel sad, sometimes until noon!" B. "I wish I didn't make so many mistakes in my homework." C. "My mom makes me special cookies when I am feeling sad." D. "When I was feeling bad, I remembered my great science project."
The patient has acute angina upon exercise. The physician starts this patient on a long-acting nitrate. Why is this medication used for acute angina?
1. It reduces blood going to vessels, reducing pain. 2. It opens vessels, increasing blood supply to the heart during exercise. 3. It controls returning blood going to the heart. 4. It thins returning blood going to the heart.
The first laboratory test that indicates type 1 diabetes is causing the development of diabetic nephropathy is:
a. Dipstick test for urine ketones b. Increase in serum creatinine and blood urea nitrogen c. Protein on urinalysis d. Cloudy urine on the urinalysis
A nurse learns from a report that a client has aortic stenosis. Where does the nurse place the stethoscope to hear this stenotic valve?
a. Second intercostal space, right sternal border b. Second intercostal space, left sternal border c. Fourth intercostal space, left sternal border d. Fifth intercostal space, left midclavicular line