Author Question: The nurse is caring for a complex patient needing physical and emotional support. As the primary ... (Read 128 times)

Mollykgkg · **on:** Jul 23, 2018

The nurse is caring for a complex patient needing physical and emotional support. As the primary care giver, the nurse:

a. is ultimately responsible for assessment of patient needs and progress.
b. delegates to people who know what they are doing and operate independently.
c. provides total care to the patient after getting direction from other disciplines.
d. understands that the patient is ultimately responsible for failure or success.

Question 2

The nursing student submits a care plan to the nursing instructor for a review prior to implementing the nursing interventions. Which of the following nursing diagnostic statements is written incorrectly?

a. Ineffective coping related to inadequate support systems as evidenced by patient's verbalization, I don't have any friends or family in town. I just moved here a week ago.
b. Activity intolerance related to immobility as manifested by shortness of breath and patient's verbalization of fatigue.
c. Insomnia and knowledge deficit related to stress as evidenced by patient report of difficulty sleeping and lack of energy.
d. Self-care deficit bathing related to upper extremity weakness as manifested by inability to wash body.

cam1229 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: A
Even though collaboration and delegation may occur, the nurse is ultimately responsible for the continued assessment of patient needs and progress. As delegator, the nurse must supervise other disciplines to make sure that the patient needs are being met. Detection of additional problems or lack of progress with the patient should prompt the nurse to reconsider the nursing process steps.

Answer to Question 2

ANS: C
Nurses must be careful when formulating nursing diagnoses. A variety of errors may occur related to clustering of unrelated data, selecting erroneous data, using medical diagnoses in the nursing diagnosis statement, and identifying multiple problems within one diagnostic statement. The student includes two separate nursing diagnostic labels in one statement.