Nursing Prioritization Clinical Judgement Practice

1. Question 1
   • Implementation
   • Evaluation
   • Diagnosis
   • Planning
2. Question 2
   • Analyzing assessment data to identify nursing diagnoses
   • Limiting documentation to physician-identified diseases
   • Reporting every routine finding without interpretation
   • Making a medical diagnosis independently
3. Question 3
   • Discard the data because analysis is restricted
   • Formulate and finalize a nursing diagnosis
   • Report the concerning data promptly to the RN
   • Replace the medical diagnosis with a nursing diagnosis
4. Question 4
   • Documented by another health professional
   • Abnormal compared with the client's age, development, or baseline
   • Common in at least one population
   • Included in a previous care plan
5. Question 5
   • As defining characteristics of every possible diagnosis
   • As expected findings whenever a client is hospitalized
   • As relevant cues requiring clinical reasoning
   • As unrelated findings because vital signs are objective
6. Question 6
   • To avoid collecting subjective data
   • To select interventions before identifying the problem
   • To determine which cues are clinically meaningful
   • To convert every finding into a medical diagnosis
7. Question 7
   • Diagnose medically, prescribe, implement, and document
   • Cluster first, collect data later, then select any available diagnosis
   • Analyze data, cluster information, form hypotheses, assess further if needed, establish statements
   • Implement, diagnose, assess, cluster, evaluate
8. Question 8
   • A routine finding expected for the client's developmental stage
   • A long-standing finding documented as the client's baseline
   • A preference that is unchanged from admission
   • A new finding that differs substantially from the client's baseline
9. Question 9
   • Objective data cannot support nursing diagnoses
   • Only medical diagnoses may use assessment findings
   • Nursing diagnoses are based on patterns of related cues
   • A diagnosis must always be selected by another discipline
10. Question 10
    • The RN documents only problems that are already treated
    • The RN identifies human responses and prioritizes them
    • The RN delegates all interpretation of assessment data
    • The RN confirms diseases diagnosed by the prescriber
11. Question 11
    • Ignore the symptom because it is subjective
    • Interpret it using the client's age, development, and baseline
    • Use the adult reference value without modification
    • Automatically label the symptom abnormal
12. Question 12
    • It replaces the need for nursing judgment
    • It identifies the medical cause with certainty
    • It removes subjective data from the assessment
    • It groups related cues into recognizable patterns
13. Question 13
    • Activity-Exercise
    • Role-Relationship
    • Nutritional-Metabolic
    • Cognitive-Perceptual
14. Question 14
    • A client's perception of body image
    • A client's exercise tolerance during daily activities
    • A client's beliefs about spiritual goals
    • A client's bowel elimination routine
15. Question 15
    • A role-relationship pattern
    • A sexuality-reproductive pattern
    • A value-belief pattern
    • A fluid-balance pattern within Nutritional-Metabolic
16. Question 16
    • Gordon's Functional Health Patterns
    • The discharge summary
    • The medication administration record
    • The medical problem list
17. Question 17
    • Cognitive-Perceptual — bowel and bladder function
    • Sleep-Rest — spiritual beliefs
    • Elimination — excretory function
    • Role-Relationship — metabolic intake
18. Question 18
    • Form a preliminary hypothesis about a nursing diagnosis
    • Assume the cluster confirms a medical diagnosis
    • Discard cues that do not fit one pattern
    • Begin implementation without establishing a problem
19. Question 19
    • Family role engagement
    • Food and fluid intake
    • Perception and cognition
    • Exercise and daily activity
20. Question 20
    • The client definitely has a medical disease
    • The data are irrelevant because no injury occurred
    • The cues support hypotheses related to safety and activity
    • The cues should be classified only as nutritional
21. Question 21
    • Health Perception-Health Management
    • Self-Perception and Self-Concept
    • Coping-Stress Tolerance
    • Value-Belief
22. Question 22
    • To eliminate the need for defining characteristics
    • To determine whether the hypothesized diagnosis is adequately supported
    • To ensure every client receives the same diagnosis
    • To change a nursing diagnosis into a medical diagnosis
23. Question 23
    • A medical diagnosis is independently established by every RN
    • A medical diagnosis describes the client's coping response
    • A nursing diagnosis identifies a human response; a medical diagnosis identifies a disease or medical problem
    • A nursing diagnosis identifies only laboratory abnormalities
24. Question 24
    • Diabetes mellitus
    • Heart failure
    • Pneumonia
    • Excess Fluid Volume
25. Question 25
    • Etiology
    • Defining characteristics
    • Problem
    • Associated condition
26. Question 26
    • A defining characteristic
    • An at-risk population
    • The related factor
    • The problem
27. Question 27
    • Due to the medical diagnosis of
    • In collaboration with
    • Related to
    • As evidenced by
28. Question 28
    • Excess Fluid Volume related to excessive fluid intake as evidenced by edema
    • Risk for Falls related to dizziness
    • Heart failure related to crackles
    • Readiness for Enhanced Health Self-Management related to heart failure as evidenced by edema
29. Question 29
    • The risk problem has not yet occurred
    • The risk diagnosis cannot be prioritized
    • The risk diagnosis always has more defining characteristics
    • The risk diagnosis identifies a disease
30. Question 30
    • The client has crackles and weight gain
    • The client has decreased lower-extremity strength
    • The client has a medical device
    • The client expresses a desire to improve health self-management

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