Deck 6: Nursing Process and Critical Thinking

Question 1

The subjective data the nurse records following a head-to-toe examination includes:

A) rash on back.
B) prolonged nausea.
C) blood pressure of 190/100.
D) white blood cell count of 19,000.

Answer 1

prolonged nausea.

Question 2

A patient with a urinary tract infection is assessed using a clinical pathway.When a projected outcome is not met by a predetermined date,it is determined that what has occurred?

A) Omission
B) Variance
C) Failure
D) Error

Answer 2

Variance

Question 3

Nursing orders,as opposed to physician's orders,prescribe activities that:

A) need an accompanying physician's order.
B) must be confirmed by the patient's request.
C) may be done independently by the nurse.
D) should not be altered or changed.

Answer 3

may be done independently by the nurse.

Question 4

On admission,the patient who should receive a focused assessment is the:

A) 53-year-old admitted with a perforated ulcer.
B) 5-year-old admitted for the implant of grommets in the middle ear.
C) 76-year-old admitted for a knee replacement.
D) 40-year-old admitted for possible bowel obstruction.

Question 5

What type of assessment is performed continuously throughout nurse-patient contact?

A) Complete
B) Body systems
C) Focused
D) Subjective

Question 6

The nurse writes two nursing diagnoses: (1)inadequate nutritional intake related to vomiting as manifested by 3-pound weight loss and (2)risk for impaired skin integrity related to inadequate nutrition.The major difference between the two diagnoses is that the second diagnosis:

A) needs no defined nursing interventions.
B) needs medical intervention.
C) will not need to be evaluated.
D) reflects a problem that does not yet exist.

Question 7

The two primary methods used to collect data are:

A) written report by patient and family.
B) review of the chart and the nurse's notes.
C) interview and physical examination.
D) review of the physician's orders and the Kardex.

Question 8

The primary purpose of nursing orders is to:

A) support physician's orders.
B) provide direction for all caregivers.
C) provide broad,general statements.
D) clarify nursing principles.

Question 9

The establishment of priorities of care during the planning phase of the nursing process often uses the framework of:

A) Erikson's developmental tasks.
B) Piaget's cognitive table.
C) Maslow's hierarchy of needs.
D) Freud's classifications.

Question 10

The basis for designing and selecting nursing interventions to meet patient needs is the:

A) nursing diagnosis.
B) care plan.
C) doctor's orders.
D) nurse's notes.

Question 11

The appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions is that the patient will:

A) increase intake to 1000 mL daily to liquefy secretions.
B) cough more frequently within 3 days.
C) breathe better within 3 days.
D) perform deep-breathing exercises four times daily.

Question 12

Information provided by the family when a patient is unable to provide data during assessment is classified as:

A) primary.
B) secondary.
C) unreliable.
D) biased.

Question 13

Objective data the nurse would include after a patient assessment includes:

A) headache of 3 days duration.
B) severe stomach cramps.
C) flatulence.
D) anxiety.

Question 14

The person responsible for analyzing and interpreting data to arrive at a nursing diagnosis is the:

A) physician.
B) LPN/LVN.
C) RN.
D) technician.

Question 15

The nursing order that is complete and correct is:

A) "May 10: Nursing assistants will ambulate patient.a. Nurse"
B) "Day nurse will cleanse wound and change dressings every day.May 10,A.Nurse"
C) "Nursing assistants will serve 8 oz glass of juice at each meal,5/10."
D) "P.M.nurse will ensure that heel protectors are in place before bedtime."

Question 16

Nursing process is best defined as a:

A) method to ensure that the physician's orders are implemented correctly.
B) series of assessments that isolate a patient's health problem.
C) framework for the organization of individualized nursing care.
D) preset formula for the design of nursing care.

Question 17

What assists the nurse in the identification of nursing diagnoses?

A) Objective data
B) Subjective data
C) Data clustering
D) Validated data

Question 18

The documentation that reflects implementation is:

A) "Patient selected low-sugar snacks independently."
B) "Patient was medicated with Tylenol 500 mg PO for pain."
C) "Patient was ambulated for 15 minutes after lunch."
D) "Patient participated in group therapy session without reminder."

Question 19

During a physical examination,the nurse discovers that the patient demonstrates signs of flushed,dry,hot skin; dry oral mucous membranes; and temperature elevation.The nurse should treat these data as the basis of a nursing diagnosis plan,as they represent:

A) symptoms.
B) data clustering.
C) signs of fluid overload.
D) urinary retention.

Question 20

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion.When performing a complete physical examination,the nurse might use an organized approach such as:

A) Maslow's hierarchy of needs.
B) a head-to-toe assessment.
C) subjective data collection.
D) objective data collection.

Question 21

A nurse is formulating a nursing diagnosis.An example of an appropriately written nursing diagnosis is:

A) risk for impaired skin integrity related to physical immobilization.
B) physical immobilization secondary to risk for impaired skin integrity.
C) risk for impaired skin integrity related to diagnosis of decubitus ulcers.
D) physical immobilization secondary to decreased cognitive ability.

Question 22

During an admission assessment the nurse collects objective and subjective data.An example of objective data is that the patient:

A) complains of chest pain.
B) states,"I feel nauseous."
C) complains of feeling faint.
D) is short of breath on exertion.

Question 23

Which is an example of a nursing diagnosis?

A) Pneumonia
B) Diabetes mellitus
C) Impaired skin integrity
D) Congestive heart failure

Question 24

Which is an example of a medical diagnosis?

A) Pain
B) Anxiety
C) Pneumonia
D) Impaired skin integrity

Question 25

The nurse uses the "risk for" nursing diagnoses as identified from the:

A) care plan.
B) interventions.
C) assessment.
D) evaluation.

Question 26

During an admission assessment the nurse collects objective and subjective data.An example of subjective data is that the patient:

A) complains of nausea.
B) is vomiting.
C) experiences tachycardia.
D) is pacing the halls.

Question 27

An example of an appropriate nursing diagnosis is:

A) constipation.
B) patient complains of constipation.
C) need for laxatives.
D) patient has a duodenal ulcer.

Question 28

An example of an appropriate nursing diagnosis is:

A) impaired skin integrity.
B) skin breakdown noted.
C) turn patient every 2 hours.
D) the patient has scabies on his back.

Question 29

During an admission assessment the nurse collects objective and subjective data.An example of objective data is that the patient:

A) complains of feeling depressed.
B) states,"I hear voices in my head."
C) complains of auditory hallucinations.
D) is pacing back and forth while chanting.

Question 30

An important consideration when developing the care plan is to ensure that:

A) the number of interventions is limited.
B) the patient is involved in the process.
C) interventions will be easy to implement.
D) evaluation of the nursing diagnoses is possible.

Question 31

Which data set is an example of a cue cluster?

A) Thirst,dry skin,dry oral mucous membranes,increased body temperature,decreased urine output
B) Elevated TSH,tachycardia,tachypnea,dry skin,anxiety,irritability,Kussmaul respirations
C) Kussmaul respirations,oliguria,polydipsia,polyphagia,low TSH,generalized discomfort
D) Elevated white blood count,neutropenia,dyspnea on exertion,generalized weakness

Question 32

During an admission assessment the nurse collects objective and subjective data.An example of objective data is the patient:

A) is jaundiced.
B) states,"I am nervous."
C) complains of palpitations.
D) denies dizziness when ambulating.

Question 33

During an admission assessment the nurse collects objective and subjective data.An example of subjective data is that the patient:

A) is asleep.
B) is tearful.
C) has facial grimacing.
D) states,"I hurt all over."

Question 34

When a problem is suspected but data to support it are lacking,the nursing diagnosis is:

A) a syndrome nursing diagnosis.
B) an actual nursing diagnosis.
C) a "risk for" diagnosis.
D) a possible nursing diagnosis.

Question 35

During an admission assessment the nurse collects objective and subjective data.An example of subjective data is the patient:

A) is coughing.
B) has cyanosis of the lips.
C) experiences tachypnea.
D) complains of generalized discomfort.

Question 36

When writing expected outcomes,the nurse should adhere to accepted criteria,which include:

A) nurse will assess vital signs every day.
B) resident will observe safety guidelines while smoking.
C) resident will take part in one activity daily for the next 90 days.
D) nurse will monitor O₂ saturation to maintain > 90%.

Question 37

When writing an actual nursing diagnosis,the "related to" part links the first two parts of the diagnosis.Complete the following nursing diagnosis appropriately.Dehydration related to:

A) lack of fluid intake.
B) excessive food intake.
C) lack of exercise.
D) bed rest.

Question 38

When a nurse selects interventions to assist the patient to meet the needs demonstrated,the nurse is in which phase of the nursing process?

A) Assessment
B) Planning
C) Implementation
D) Evaluation

Question 39

Which is an example of a medical diagnosis?

A) Constipation
B) Diabetes mellitus
C) Impaired skin integrity
D) Altered nutrition: less than body requirements

Question 40

The patient is confined to bed rest,which contributes to immobility.Bed rest would then be considered:

A) contributing to the patient's recovery.
B) a risk factor.
C) difficult to maintain.
D) a nursing responsibility.

Question 41

Human responses to levels of wellness in an individual,family,or community that have a readiness for enhancement are known as a _____________ ____________ ____________.

Question 42

Which are acceptable secondary sources for data? (Select all that apply.)

A) Patient
B) Family members
C) Other health professionals
D) Diagnostic reports
E) Textbooks

Question 43

Human responses to health conditions and life processes that may develop in a vulnerable individual,family,or community are known as a __________ __________ ____________.

Question 44

The standards that name and measure patient outcomes are referred to as ___________.

Question 45

Any health care condition that requires diagnostic,therapeutic,or educational actions is known as a ______________.

Question 46

The identification of a disease or condition by a scientific evaluation of physical signs,symptoms,history,laboratory test,and procedures is known as a _________ _______.

Question 47

A health care system that provides control over heath care services for a specific group of individuals in attempts to control cost is known as ___________ ______________.

Question 48

Which are considered phases of the nursing process? (Select all that apply.)

A) Diagnosis
B) Planning
C) Assessment
D) Evaluation
E)Implementation
F)Outcome identification

Question 49

Which are official categories of nursing diagnoses? (Select all that apply.)

A) Actual
B) Risk
C) Wellness
D) Syndrome
E) Potential

Question 50

A clinical judgment about individual,family,or community responses to actual or potential health problems/life processes is known as a _____________ ___________.

Question 51

The document that outlines a multidisciplinary plan for care interventions over a specified time frame is a _______ ________.

Question 52

A systemic,dynamic process by which the nurse,through interaction with the patient,significant others,and health care providers,collects and analyzes data about the patient is known as ______________________.

Question 53

The human responses to health conditions/life processes that exist in an individual,family,or community are known as a(n)_________ _______________ _____________.

Question 54

A systematic method by which nurses plan and provide care for patients is known as the _________ ____________.

Question 55

NANDA International meets to reorganize diagnosis labels and language every ______ years.

Question 56

A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk,high-volume,high-cost types of cases is known as a ___________ ____________.