Answer to Question 1
ANS: B
Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.
Answer to Question 2
ANS: D
When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory. See relationship to audience response question.
In the communication technique of collaborating, the nurse sends the message that the nurse and pati
The nurse needs to note the source of the patient health history
Percussion for Ascites: Shifting Dullness, Patient on Left Side
An example of a medical history sheet to list patient problems.
Trapezius muscle movement
Ciliary movement