Question 1

Which of the following group of terms best defines assessing in the nursing process?&#10;A) problem focused, time lapsed, emergency based&#10;B) design a plan of care, implement nursing interventions&#10;C) collection, validation, communication of patient data&#10;D) nurse focused, establishing nursing goals

Accepted Answer

Assessing in the nursing process involves the collection, validation, and communication of patient data to inform the development of a plan of care and implementation of nursing interventions. It is not problem focused, time lapsed, emergency based or nurse focused, nor does it involve establishing nursing goals alone.

Question 2

On admission, a physician diagnoses a patient with rheumatoid arthritis. The nurse uses assessments to make the nursing diagnosis of Chronic Pain. What is the nurse diagnosing?&#10;A) the pathology of the illness&#10;B) the response of the patient to the illness&#10;C) information from a nursing textbook&#10;D) knowledge from more experienced nurses

Accepted Answer

The nurse is diagnosing the patient's response to the illness, as evidenced by the assessment of chronic pain. The nursing diagnosis is based on the subjective and objective data collected during the assessment of the patient's physical and emotional wellbeing. It is not based on the pathology of the illness, information from a nursing textbook, or knowledge from more experienced nurses.

Question 3

Which of the following statements best describes the relationship between nursing diagnosis and medical diagnosis?&#10;A) The nursing diagnosis confirms the medical diagnosis.&#10;B) The nursing diagnosis duplicates the medical diagnosis.&#10;C) There is no relationship between nursing and medical diagnoses.&#10;D) The nursing diagnosis is based on patient response to the medical diagnosis.

Accepted Answer

Nursing diagnosis is based on patient response to the medical diagnosis. While the medical diagnosis looks at the disease or condition itself, nursing diagnosis focuses on how the patient is responding to it and how it affects their overall health and well-being. Nursing diagnosis helps in planning interventions that can help the patient manage the condition and promote health.

Question 4

Who or what is the primary source of information for a nursing history?&#10;A) previous medical records&#10;B) other healthcare personnel&#10;C) the patient&#10;D) family members

Accepted Answer

The patient is considered the primary source of information for a nursing history because they can provide firsthand accounts of their symptoms, health history, and concerns.

Question 5

What type of patient record data would the nurse find in the medical history and progress notes?&#10;A) findings of the physician's assessment and treatment&#10;B) results of laboratory and diagnostic studies&#10;C) nursing documentation and plan of care&#10;D) information from other members of the healthcare team

Accepted Answer

The medical history and progress notes primarily contain the findings of the physician's assessment and treatment, documenting the patient's condition over time and the physician's medical decision-making process.

Question 6

Of the following data, what type would be collected during a physical assessment?&#10;A) color, moisture, and temperature of the skin&#10;B) type, amount, and duration of pain&#10;C) foods eaten that cause nausea&#10;D) specific allergies resulting in itching

Accepted Answer

The color, moisture, and temperature of the skin are physical characteristics that can be observed and measured during a physical assessment. The other options relate more to medical history and subjective symptoms.

Question 7

After collecting data from a patient with respiratory distress, the nurse prioritizes the patient interventions to provide oxygen to the patient first. This is an example of which of the following models for organizing data?

A) Hierarchy of Human Needs
B) Functional Health Patterns
C) Human Response Patterns
D) Body Systems Model

Accepted Answer

The nurse's prioritization of providing oxygen to a patient with respiratory distress first aligns with Maslow's Hierarchy of Human Needs, which emphasizes the importance of meeting physiological needs (such as breathing) before addressing higher-level needs. Oxygenation is a basic physiological need, making this approach an example of the Hierarchy of Human Needs model.

Question 8

A student takes an adult patient's pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next?&#10;A) Record the pulse rate on the appropriate vital signs sheet in the chart.&#10;B) Ask the instructor or a staff nurse to take the pulse.&#10;C) Discuss this finding during postconference with other students.&#10;D) Wait 4 hours and take the patient's pulse again.

Accepted Answer

A pulse rate of 20 beats/min is extremely low and could indicate a serious medical condition. Asking an instructor or staff nurse to take the pulse can help confirm the reading and determine if further medical intervention is needed. Recording the pulse rate on the vital signs sheet is important, but not the priority in this situation. Discussing the finding during postconference is also important, but should not delay taking action. Waiting four hours to take the pulse again could put the patient at risk if the low pulse rate is a sign of a serious medical condition.

Question 9

Which of the following entries would be an example of appropriate documentation?&#10;A) Patient appears depressed and tired.&#10;B) &#34;I am so down today, and I just don't have any energy.&#34;&#10;C) Patient had a good bowel movement.&#10;D) Complains of abdominal pain. Probably constipated.

Accepted Answer

This entry is a direct quote from the patient and provides a clear description of the patient's emotional and physical state. It is important to use direct quotes or objective observations in documentation. The other options are subjective or incomplete descriptions that do not provide enough information for proper documentation.

Question 10

Which of the following statements indicates that a plan to assist a patient in developing and following an exercise program has been effective?&#10;A) &#34;I have just been too busy to do my daily exercises.&#34;&#10;B) &#34;I guess I will begin the activity we discussed next week.&#34;&#10;C) &#34;I know I should exercise, but my health is not very good.&#34;&#10;D) &#34;I have lost 10 pounds because I walk 2 miles every day.&#34;

Accepted Answer

The statement "I have lost 10 pounds because I walk 2 miles every day" indicates that the patient has successfully developed and followed an exercise program, resulting in weight loss. The other statements suggest that the patient may be struggling to adhere to the plan or may have reservations about exercising.

Question 11

A nurse working in an outpatient surgery center is responsible for taking a health history and performing a physical assessment on each patient scheduled for surgery. Why is establishing this database so important for nursing care?

A) to ensure good nurse-patient relationships before surgery
B) to ensure medical and surgical safety
C) it is a routine part of any admission procedure
D) to identify strengths and problems

Accepted Answer

The answer of A nurse working in an outpatient surgery...

Question 12

A nurse believes her employer has violated the law and reports this to the appropriate law enforcement agency. What is this type of action called?&#10;A) short stopping&#10;B) whistle-blowing&#10;C) mud smearing&#10;D) low balling

Accepted Answer

The answer of A nurse believes her employer has violated...

Deck 9: Assessing; and Blended Skills and Critical Thinking Throughout the Nursing Process