Deck 5: Nursing Process: Foundation for Clinical Judgment

Question 1

Based on the work of Marjory Gordon and the nursing process, which component is associated with problem identification?

A) Assessment
B) Outcome projection
C) Intervention
D) Outcome evaluation

Answer 1

Assessment

Question 2

Based on the work of Marjory Gordon and the nursing process, which component is associated with problem identification?

A) Assessment
B) Outcome projection
C) Intervention
D) Outcome evaluation

Answer 2

Assessment

Question 3

The term nursing process is synonymous with the:

A) identification of health problems.
B) verification of wellness issues.
C) application of nursing diagnosis.
D) problem-solving approach.

Answer 3

problem-solving approach.

Question 4

The nurse caring for a newly admitted client recognizes that the client's past medical record from previous admissions at an acute care facility is considered to be the:

A) primary source.
B) secondary source.
C) subjective data.
D) nursing diagnosis.

Question 5

Which healthcare professional is licensed to make a nursing diagnosis?

A) Licensed practical nurse
B) Registered nurse
C) Social worker
D) Physician assistant

Question 6

The nurse writes the following on the client's chart: The client will show complete healing of the surgical incision on the right lower quadrant of the abdomen in 3 weeks. This is a(an):

A) nursing diagnosis.
B) assessment.
C) evaluation.
D) outcome identification.

Question 7

What is the primary goal of the planning phase of the nursing process?

A) To identify goals for the client
B) To prepare a plan of care
C) To establish priorities for care
D) To acknowledge client needs

Question 8

After the nurse has formulated expected outcomes, the next step of the nursing process is to:

A) outline evaluation strategies.
B) prepare an oral report.
C) document the rationale.
D) write the plan of care.

Question 9

When the nurse formulates three nursing diagnoses for an adult client hospitalized for abdominal surgery, the nurse has focused on the client's:

A) medical record.
B) actual health problems.
C) medical diagnosis.
D) past medical history.

Question 10

The nurse changes a client's surgical dressing daily. This is considered to be part of which phase of the nursing process?

A) Nursing diagnosis
B) Client goal
C) Outcome identification
D) Implementation

Question 11

Nursing actions should be:

A) associated with the family.
B) goal-directed.
C) individually attained.
D) evaluated by team members.

Question 12

A client had surgery 3 weeks ago, and now the nurse notes that the client has partial healing of the surgical wound. This assessment would occur in which phase of the nursing process?

A) Outcome
B) Nursing diagnosis
C) Planning
D) Evaluation

Question 13

A nurse is conducting an assessment of a client. Which information would the nurse identify as a primary source?

A) Client's complaints about abdominal pain at a rating of 8
B) Family member's report of client's pain level
C) Phone call with client's primary practitioner about admission
D) Test results from a previous admission

Question 14

A nurse ascertains that the client is showing signs and symptoms of dehydration due to nausea and vomiting. The nurse makes the client n.p.o. (nothing by mouth) and calls the physician. The nursing action of making the client n.p.o. is the result of:

A) general systems theory process.
B) general adaptation theory.
C) decision-making process.
D) information-processing theory.

Question 15

A nursing student is developing interpersonal skills. Which method would best facilitate this type of learning?

A) Actively reading the assigned text
B) Writing extensive nursing plans of care
C) Participating in communication courses
D) Practicing in the skills lab

Question 16

When the nurse administers pain medication to a postoperative client, the phase of the nursing process that is occurring is:

A) assessment.
B) nursing diagnosis.
C) planning.
D) implementation.

Question 17

The nurse assesses a client's blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. What action has the nurse implemented?

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

Question 18

A client who has limited finances and limited capacity for education requires home healthcare for a chronic illness. For the nurse to provide a high level of care to this client, which action would the nurse do first?

A) Implement critical-thinking skills.
B) Develop a relationship with the client.
C) Engage the services of a social worker.
D) Determine what care has been provided.

Question 19

A nurse is integrating knowledge learned in the classroom with a clinical client situation. The nurse is using which skill?

A) Communication
B) Clinical reasoning
C) Collaboration
D) Active listening

Question 20

A nursing student is working on using critical thinking skills to develop expertise. The student is applying information learned from instructors, clinical laboratory skills, and textbook readings. The student is at which level of expertise?

A) Novice
B) Advanced beginner
C) Competence
D) Expert

Question 21

What type of learning best takes place in the nursing laboratory?

A) Kinesthetic learning
B) Auditory learning
C) Concrete learning
D) Collaborative learning

Question 22

In order to implement the most effective care for clients, a nursing student must:

A) have expert-level critical-thinking skills.
B) apply preexisting knowledge to present situations.
C) replace theoretic knowledge with practical knowledge.
D) maintain a detailed clinical log for evaluation.

Question 23

A nursing student is caring for a client who has diabetes mellitus. The client takes insulin two times per day. Based on the student's knowledge of insulin's onset of action, the student makes sure the client's meals arrive in coordination with the insulin's effect. The knowledge used by the student is:

A) evaluative.
B) lacking.
C) integrated.
D) creative.

Question 24

A client complains of weakness following his administration of insulin. The nurse decides to assess the client's blood sugar and prepare a snack in case the blood sugar is low. What action has the nurse implemented?

A) Clinical reasoning
B) Caring
C) Reflection
D) Assessment

Question 25

The nurse is caring for a newly admitted client. How can a nurse arrive at a more complete database for this client?

A) Through clustering of data
B) Analysis of lab values
C) Review of the chart
D) Consult with several sources

Question 26

What is meant by intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new meanings and appreciations?

A) Memorization
B) Reflection
C) Reminiscing
D) Evangelization

Question 27

A modern approach to the development of clinical decisions and clinical judgments is the use of human patient simulators in simulation laboratories on campus. Human patient simulators are best described as:

A) life-sized mannequins with a sophisticated computer interface.
B) small, doll-like devices used for measuring vital signs.
C) healthcare equipment that has practice modes.
D) life-saving equipment that resuscitates clients in cardiac arrest.