Question 1

A nursing student is learning how to implement the nursing process in the clinical area. The purpose of the diagnosis phase will teach the student to:

Accepted Answer

The diagnosis phase of the nursing process involves identifying nursing and collaborative problems based on the data collected during the assessment phase. This helps the nurse to develop an individualized care plan that addresses the patient's specific needs and goals. Implementing a standardized care plan would not allow for individualized care. Assessing whether patient goals have been met occurs during the evaluation phase. Organizing and validating data occurs during the assessment phase.

Question 2

A client has been using the call light routinely throughout the evening. Upon now entering the room, the nurse becomes aware of an odour not observed previously. This is an example of:

Accepted Answer

The presence of an odour is an objective observation that can be measured and observed by others. The use of the call light and the timing of it may be subjective, incomplete, or secondary data.

Question 3

A client was admitted just prior to the shift change. The admitting nurse reported most of the information to oncoming staff, but did not have all of the client's past records. The second nurse is completing the assessment and database and continues to question the client about much of the same information as the previous nurse. The second nurse is following this process so as to:

Accepted Answer

The second nurse is completing the assessment and database and continues to question the client about much of the same information as the previous nurse so as to validate and update the data. This ensures that all information is accurate and up-to-date, which is crucial in providing safe and effective care for the client.

Question 4

A nurse has delegated to a student nurse to obtain vital signs for a newly admitted client. The student reports the following: temperature = 37.4 °C, respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. To validate the data, the best action by the nurse is to:

Accepted Answer

The high blood pressure reading of 200/146 needs to be validated as it could indicate a potential health concern. The nurse should reassess the blood pressure to ensure accuracy before taking any further action. Reporting to the Clinical Nurse Consultant or calling the physician may not be necessary at this point until further assessment is completed. Continuing with the physical assessment without rechecking the vital signs may lead to an incomplete or inaccurate assessment.

Question 5

The nurse is collecting information from a client's family. The client is confused and not able to contribute to the conversation. The spouse states: "This is not his normal behaviour". The nurse documents this as which of the following?

Accepted Answer

Secondary subjective data is information provided by someone other than the patient, such as a family member, about the patient's condition.

Question 6

The nurse is taking information for the client's database. The client is not very talkative, is pale, diaphoretic, and restless in the bed and tells the nurse to, "Just leave me alone". Which of the following is subjective data?

Accepted Answer

"Just leave me alone" is the only option that represents the client's own words and feelings, making it subjective data. The other options (restlessness, not talkative, pale and diaphoretic) are objective data that can be observed and measured.

Question 7

An infant has been admitted to the paediatric unit. The parents are quite worried and the grandmother is also present. In this situation, what would be the best source of data?

Accepted Answer

The parents are typically the best source of data regarding an infant's health and history, even if they are worried, as they are most likely to have the most comprehensive and relevant information about the child's condition and medical history.

Question 8

Which of the following would be categorised as 'psychological data'?

Accepted Answer

Psychological data refers to information related to mental processes and behavior. Major stressors are directly related to psychological states and can impact mental health.

Question 9

A nurse has just been informed that a new admission is coming to the unit. According to the Australian Council on Healthcare Standards (2013), how long does the nurse have to complete a physical assessment and have a documented history and physical on the chart?

Accepted Answer

According to the Australian Council on Healthcare Standards (2013), a nurse has 24 hours to complete a physical assessment and have a documented history and physical on the chart for a new admission.

Question 10

When learning how to implement the nursing process into a plan of care for a client, the student nurse realises that part of the purpose of the nursing process is to:

Accepted Answer

The purpose of the nursing process is to identify client needs and deliver care to meet those needs in an organised way. It is not about standardised care or a medical model.

Question 11

The nurse makes the decision to look at alternatives for wound care with a client who has a stasis ulcer that has been treated over the past two weeks. The nurse was hopeful to see some improvement by this time. This represents which phase of the nursing process?

Accepted Answer

The nurse has already completed the assessment and implementation phases by treating the stasis ulcer for two weeks. The decision to look at alternative wound care options indicates that the nurse is evaluating the effectiveness of the current treatment plan. Therefore, this represents the evaluation phase of the nursing process.

Question 12

A nurse is working in the operating room with a client just prior to the procedure. While setting up for the procedure, the nurse notices that the client has become unresponsive and respirations have become shallow. What type of assessment would be necessary in this situation?

Accepted Answer

The situation described requires an emergency assessment, as it involves a sudden change in the client's condition that requires immediate intervention. An initial assessment is typically done upon admission to the healthcare facility and does not involve an acute change in condition. A problem-focused assessment is done to investigate a specific problem, while a time-lapsed assessment is done over a period of time to track changes or trends in the client's condition.

Question 13

A nurse is performing an initial assessment on a new admission. Which of the following is not a part of the database?

Accepted Answer

Physician's orders are not part of the nurse's initial assessment of the client. They are part of the client's medical record and are generated by the physician's evaluation of the client's condition. The other options listed are all areas of focus for the nurse's initial assessment to establish a comprehensive database for the client.

Question 14

A nurse is undertaking an initial nursing assessment of a client who has been recently admitted to the ward. The purpose of this initial assessment is to:

Accepted Answer

The purpose of an initial nursing assessment is to establish a baseline database of the client's health status, medical history, and current problems. This provides a starting point for ongoing nursing care and helps to identify changes in the client's condition over time. The other options (B, C, D) do not accurately reflect the purpose of an initial nursing assessment.

Question 15

A nurse is providing a back rub to a client just after administering a pain medication with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse applying?

Accepted Answer

The nurse is implementing a nursing intervention (back rub) just after administering pain medication in order to address the client's pain. This falls under the Implementation phase of the nursing process.

Question 16

The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process?

Accepted Answer

The nurse is in the assessment phase of the nursing process when they notice a new area of skin breakdown and identify its cause as being related to the tape used for the dressing. This phase involves collecting data to understand the patient's current health status and needs.

Question 17

The nurse makes this entry in the client's chart: "Client avoids eye contact and gives only vague, non-specific answers to direct questioning by the professional staff. However, the client is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse." This is an example of which method of data collection?

Accepted Answer

This is an example of observing, as the nurse is watching and noting the client's behavior and nonverbal cues.

Question 18

One critical-thinking activity that a nurse can develop during the assessment phase of the nursing process is that of:

Accepted Answer

The answer of One critical-thinking activity that a nurse can...

Question 19

The nurse uses critical-thinking skills when using the nursing process to diagnose after an initial assessment. This is reflected when the nurse:

Accepted Answer

Finding patterns among cues is a crucial step in the nursing process of diagnosis. It involves analyzing the data collected during the initial assessment to identify any signs or symptoms that may indicate an underlying health problem. This requires critical thinking skills such as organizing and interpreting data, identifying relationships between different cues, and making inferences based on the available evidence. While making reliable observations, performing client-focused interventions, and making interdisciplinary connections are also important aspects of the nursing process, they are not directly related to the diagnostic process of nursing.

Question 20

The nursing process enables the nurse to respond to:

Accepted Answer

The nursing process is a systematic approach for providing patient care that includes assessment, diagnosis, planning, implementation, and evaluation. This process enables the nurse to respond to the changing health status of the patient, which can include identifying new symptoms or complications, adjusting the care plan accordingly, and communicating with other healthcare professionals as needed. The other options (A, C, and D) do not necessarily require the nursing process to be applied.

Quiz 12: Assessing