Deck 12: The Nursing Process and Critical Thinking

Question 1

The nurse uses palpation for the purpose of:

A) Determining areas of tenderness.
B) Differentiating between fluid- and air-filled organs.
C) Hearing sounds produced by the body.
D) Systematically approaching a physical assessment.

Answer 1

Determining areas of tenderness.

Question 2

The patient complains of a headache.This information would be classified as:

A) Subjective
B) Objective
C) Pain assessment
D) Undifferentiated

Answer 2

Subjective

Question 3

The nursing process is based on:

A) Medical diagnosis of the patient
B) Identified physiologic and psychologic needs of the patient
C) Standards of nursing care provided by the American Nurses' Association
D) Orders of the primary care provider

Answer 3

Identified physiologic and psychologic needs of the patient

Question 4

Data collection consists of:

A) Information supplied by patient and family
B) Health history, physical assessment, and documentation
C) Health history and physical assessment
D) Assessment, patient records, and diagnostic tests

Question 5

When the postsurgical patient complains of shortness of breath,the nurse should immediately:

A) Raise the head of the bed to 30 degrees.
B) Take vital signs.
C) Perform a focused assessment.
D) Inform the charge nurse.

Question 6

The five steps of the nursing process,in the correct order,are:

A) Data collection, nursing diagnosis, planning, intervention, and evaluation.
B) Assessment, planning, documentation, intervention, and evaluation.
C) Data collection, diagnosis, assessment, planning, and evaluation.
D) History, physical, diagnosis, intervention, and evaluation.

Question 7

The nurse assisting with prioritizing nursing diagnoses would select which of the following as the highest priority?

A) Impaired adjustment
B) Acute pain
C) Risk for imbalanced body temperature
D) Ineffective airway clearance

Question 8

The best example of a nursing order is:

A) Perform deep breathing exercises twice daily at 10 AM and 2 PM.
B) Administer Tylenol every 4 hours as needed for headache.
C) Assess skin integrity and risk for impairment.
D) Patient will frequently perform quadriceps-setting exercises.

Question 9

The primary purpose of incorporating the nursing process into the care of patients is to:

A) Establish a basis of communication with other nursing staff members.
B) Maintain compliance with existing national nursing standards.
C) Provide structure and organization to the delivery of medical care to the patient.
D) Address current health issues, as well as health maintenance and rehabilitation.

Question 10

The nurse notes the previous 24-hour urine output was 950 ml,well below the normal of 1500 ml.An effective nursing order to remedy the impending dehydration would be to:

A) Offer more fluids daily.
B) Offer 8 ounces of juice or tea at 0800 (8 AM), 1200 (12 noon), 1600 (4 PM), and 2000 (8 PM).
C) Request extra fluid on a diet tray from the kitchen.
D) Place a large water pitcher at the bedside during each shift.

Question 11

Nursing outcome classification (NOC)is a method of classifying a nursing:

A) Process
B) Care plan
C) Goal
D) Intervention outcome

Question 12

The nursing care plan is initiated by the:

A) Primary care provider
B) Registered nurse (RN)
C) Licensed practical/vocational nurse (LPN/LVN)
D) Nurse manager

Question 13

When a patient plan of care has been written,it:

A) Is continually reviewed and evaluated.
B) Must be reviewed by the primary caregiver.
C) Remains in effect until the patient is discharged.
D) Can only be changed by the initiating nurse.

Question 14

The patient will maintain an adequate nutritional state without nausea or vomiting is an example of a nursing:

A) Intervention
B) Process
C) Diagnosis
D) Goal

Question 15

The documentation entry that reflects objective data is:

A) An area of erythema is noted on the upper right extremity, measuring approximately 1 ´ 4 inches.
B) Patient complains of pain in the right left quadrant (RLQ) of the abdomen and rates it 5 on a pain scale of 1 to 10.
C) Family states that the patient does not sleep at night and wanders around the house.
D) Medical reveals a history of drug abuse.

Question 16

Standardized care plans are:

A) Clinical pathways
B) Evaluation tools
C) Outcome criteria
D) Nursing intervention-based

Question 17

An example of a complete nursing diagnosis is:

A) Peripheral neurovascular dysfunction
B) Peripheral neurovascular dysfunction exhibited by patient complaint
C) Peripheral neurovascular dysfunction related to decreased sensation, exhibited by the statement, "My feet are tingling."
D) Peripheral neurovascular dysfunction exhibited by patient statement

Question 18

Nursing interventions classifications (NIC)are:

A) Mandated by the North American Nursing Diagnosis Association (NANDA) as interventions that are to be used for all patients.
B) Currently approved nursing goals.
C) Instituted on the basis of individual patient needs.
D) Guidelines for goal setting and documentation of nursing care given to patients.

Question 19

When percussing the patient's abdomen,the nurse anticipates a note that is:

A) Flat
B) Dull
C) Tympanic
D) Resonant

Question 20

The nurse is aware of the goal that reads,"The patient will eat at least 50% of all meals." The nurse has observed the patient eating over 50% of all meals for 2 days.The evaluation statement should read:

A) Ate well for all meals.
B) Problem is resolved; goal is met.
C) Goal is met; patient ate 50% of all meals on 7/12 and 7/13.
D) Ate 50% of meals.

Question 21

Evidence-based practice supports effective nursing care through:

A) Research on nursing care topics
B) Directives from the Boards of Nursing
C) Summation of studies
D) Recommendations for nursing care
E) Funding research

Question 22

The most effective documentation is:

A) 7/27; 9:45 AM; pt. vomited; pt. looked better after episode-A. Nurse, LPN
B) 7/27; 9:45 AM; pt. vomited large amount; reduced nausea
C) 7/27; 9:45 AM; pt. reported less nausea after vomiting-A. Nurse, LPN
D) 7/27; 0945; pt. vomited 200 ml of partially digested food; pt. states nausea has diminished-A. Nurse, LPN

Question 23

The nurse who exhibits an open minded,professionally curious,mature and self confident approach to care would be considered a ________________ ________________

Question 24

Critical thinking is an integral part of the nursing process because it:

A) Promotes flexibility and individualized care.
B) Incorporates decision making.
C) Includes the patient in part of the nursing process.
D) Provides guidelines of care.

Question 25

Problem-oriented medical records (POMRs):

A) Focus on patient response to treatment.
B) Is source-oriented charting.
C) Reflect the patient's current problems.
D) Focus on medical diagnosis.

Question 26

Characteristics of critical thinking include:

A) Interpretation, analysis, and evaluation
B) Patient-centered criteria and problem solving
C) Realistic outcomes and frequent evaluation
D) Data gathering and assessment

Question 27

In PIE documentation,a type of POMR,the acronym PIE stands for ____________________,____________________ and ____________________.

Question 28

The nurse auscultating the patient's chest will:

A) Use the diaphragm for assessing breath sounds.
B) Use the bell for assessing murmurs.
C) Apply earpieces pointing toward the ears.
D) Wet the chest hair with a cloth.
E) Press the diaphragm very firmly against the chest wall.

Question 29

Documentation should include:

A) Objective and subjective data
B) Observations made by other nursing staff
C) Information that is accurate and complete
D) Incidence reports

Question 30

Examine this goal statement: Patient will walk in the hall unassisted.The two missing components for a correctly stated goal in this example are the descriptors for ____________________ and ____________________.