Deck 4: The Nursing Process and Decision Making

Question 1

A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies as subjective data that

A) The patient is short of breath.
B) The patient has wound drainage.
C) The patient has low blood pressure.
D) The patient reports feelings of fatigue.

Answer 1

The patient reports feelings of fatigue.

Question 2

While performing a shift assessment, a nurse touches and feels a patient's pulses bilaterally. This is an example of an assessment technique called

A) Palpation.
B) Inspection.
C) Percussion.
D) Auscultation.

Answer 2

Palpation.

Question 3

A nursing instructor explains that a complete nursing diagnosis may be a one-part, two-part, or three-part statement. Three-part statements are often called PES statements, which stands for

A) Prognoses, examination, and solution.
B) Problem, etiology, and signs and symptoms.
C) Pathogen, etymology, and symptoms.
D) Problems, evaluations, and solutions.

Answer 3

Problem, etiology, and signs and symptoms.

Question 4

While performing a focused assessment, a nurse listens to a patient's heart and lung sounds. This is an example of an assessment technique called

A) Palpation.
B) Inspection.
C) Percussion.
D) Auscultation.

Question 5

A nurse receives an order from the physician for an intravenous (IV) antibiotic to be administered to a patient who has experienced development of pneumonia. The nurse remembers that the patient has an allergy to another medication in the same family of antibiotics. The nurse should

A) Retest the patient for allergies.
B) Call the laboratory for clarification.
C) Notify the physician of the potential for the patient to have a reaction to the ordered antibiotic.
D) Follow the physician's orders and administer the IV.

Question 6

While caring for a patient who is complaining of abdominal pain, the nurse determines that the top priority is to manage the patient's pain with medication. This step in the nursing process is called

A) Planning.
B) Diagnosis.
C) Assessment.
D) Implementation.

Question 7

A nurse is caring for a patient with asthma who is having difficulty breathing. The nurse notifies the respiratory therapist, who administers treatment. After the treatment, the nurse reflects on the results to determine whether the goal of relief has been accomplished. When the nurse determines whether the goal has been met, he or she is performing a step in the nursing process called

A) Planning.
B) Diagnosis.
C) Evaluation.
D) Implementation.

Question 8

A nurse admits a patient and selects the priority nursing diagnosis of acute pain. The nurse plans to administer pain medication as needed. When the patient complains of pain, the nurse medicates the patient. Next, the nurse should

A) Assess the patient's laboratory values.
B) Create a new nursing diagnosis.
C) Administer an additional dose of medication.
D) Evaluate the effects of the medication.

Question 9

While performing a shift assessment, a nurse visually examines a patient's body for rashes and breaks in the skin, and looks for normal appearance of eyes, ears, nose, mouth, limbs, and genitals. This is an example of an assessment technique called

A) Palpation.
B) Inspection.
C) Percussion.
D) Auscultation.

Question 10

While reviewing the nursing diagnoses in a student nurse's written care plan, a nursing instructor recognizes that additional teaching is warranted when the student nurse includes a nursing diagnosis of

A) "Pain related to abdominal incision."
B) "Altered sensory perception related to surgery."
C) "Chronic fatigue syndrome related to poor diet."
D) "Altered nutrition related to nausea and vomiting."

Question 11

A licensed practical nurse (LPN) has formulated four nursing diagnoses for her patient. The priority nursing diagnosis would be

A) Altered nutrition.
B) Risk for infection.
C) Chronic low self-esteem.
D) Ineffective airway clearance.

Question 12

While caring for a newly admitted patient, a registered nurse (RN) gathers information by interviewing the patient to obtain a health history and reviewing the results of laboratory and diagnostic tests. This step in the nursing process is called

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

Question 13

While performing an assessment, a physician taps on the patient's abdomen to detect abnormalities. This is an example of an assessment technique called

A) Palpation.
B) Inspection.
C) Percussion.
D) Auscultation.

Question 14

Student nurses are encouraged to practice using skillful reasoning and logical thought to determine the merits of a belief or action. This approach best describes

A) Critical thinking.
B) Sensory overload.
C) Concrete thinking.
D) Logical reasoning.

Question 15

A nurse is caring for a patient who has a broken leg. When the patient complains of pain, the nurse administers additional pain medication. When the nurse medicates the patient, he or she is performing a step in the nursing process that is called

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

Question 16

A nurse is performing a shift assessment on a patient. While collecting objective and subjective data, the nurse identifies as objective data that

A) The patient reports feelings of depression.
B) The patient demonstrates facial grimacing.
C) The patient complains of feeling nauseated.
D) The patient complains of visual disturbances.

Question 17

The health-care team member responsible for performing a patient assessment and formulating nursing diagnoses is

A) The medical doctor (MD).
B) The registered nurse (RN).
C) The licensed practical nurse (LPN).
D) The unlicensed assistive personnel (UAP).

Question 18

The nursing process is a

A) Decision-making framework used by nurses to determine the needs of patients.
B) Decision-making framework used by social workers when discharging patients.
C) Decision-making framework used by nursing assistants when caring for patients.
D) Decision-making framework used by physicians to determine the needs of patients.

Question 19

While performing an admission history on a confused patient, a licensed practical nurse (LPN) assists the registered nurse (RN) by collecting secondary information about the patient. An example of secondary information would be that

A) The patient reports a history of chest pain.
B) The patient complains of chronic constipation.
C) The patient verbalizes anxiety about hospitalization.
D) The patient's spouse reports experiencing marital issues.

Question 20

While performing a thorough physical assessment on a patient, the licensed practical nurse (LPN) begins collecting primary data. An example of primary data is that

A) The patient's spouse reports the patient has difficulty sleeping.
B) The patient's caregiver complains of feeling overwhelmed.
C) The patient reports a history of chronic obstructive pulmonary disease.
D) The patient's daughter appears anxious about the patient's hospitalization.

Question 21

A student nurse demonstrates understanding of outcome statements by saying which of the following?

A) "An outcome statement should be a realistic, specific action."
B) "An outcome statement is an action that is measurable and can be evaluated."
C) "An outcome statement should be an action the patient is unable to perform."
D) "An outcome statement should be a specific action to be taken by the nurse."
E) "An outcome statement has a definite time frame for

Question 22

A student nurse may be required to prepare for clinical experiences by completing a portion of a care plan form before actually caring for a patient. Place the following student care plan preparation steps in the correct order (Enter using the following format: 1, 2, 3, 4).
1. Expected outcomes
2. Research
3. Develop interventions
4. Possible nursing diagnoses

Question 23

A nursing instructor is teaching students the importance of individualized nursing interventions. The instructor recognizes that a student nurse understands when he or she

A) Encourages a patient to increase fluid intake.
B) Assesses a patient for signs and symptoms of dehydration.
C) Records a patient's fluid intake and output.
D) Asks a patient which type of fluid he or she would like to drink.

Question 24

After increasing fluid intake and administering stool softeners for a patient complaining of constipation, a nurse calls the physician to obtain an order to administer an enema. This is an example of a(n)

A) Dependent intervention.
B) Indirect intervention.
C) Independent intervention.
D) Collaborative intervention.

Question 25

A care plan is often used as a basis for documentation. The type of plan that contains areas for respiratory therapists, social services workers, physical therapists, and dietitians to document their plans and the patient's response is called a

A) Multidisciplinary care plan.
B) Standardized care plan.
C) Computerized care plan.
D) Student care plan.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Question 26

The nurse understands that when the nursing diagnosis is one that expresses the risk for a problem, a possible problem, or certain actual problems, the ____________________ statement, referred to as a PE statement, is used.

Question 27

The nurse recognizes that a(n) ____________________ can be used to diagram and connect data about any subject. It can help the nurse see relationships between nursing diagnoses and assessment data, and help him or her make connections between interventions and diagnoses.

Question 28

Nurses who use critical thinking avoid jumping to conclusions about patients or patient care, and they also avoid making decisions based on assumptions. They ____________________, or ensure the correctness of, any information they obtain.

Question 29

One of the initial steps of a nursing ____________________ is a nurse introducing himself or herself to the patient if he or she has not previously done so. The nurse includes his or her name and title, as in, "I'm Jane Johnson, a student nurse."

Question 30

Examples of indirect patient care include which of the following? A!. Bathing a patient

A) Bathing a patient
B) Administering pain medication
C) Documenting a patient's bath
D) Listening to a patient's complaints
E) Informing the physician about a patient's pain

Question 31

A standardized ____________________ is a preprinted document with typical nursing diagnoses and corresponding nursing intervention choices to coordinate with a particular medical diagnosis.

Question 32

A nursing instructor explains to students that the ____________________ list contains nursing diagnoses that are standardized and arranged with the primary topic first, followed by modifiers.

Question 33

Once a student nurse has completed the preparation steps of his or her student care plan, he or she will be ready for the actual clinical experience. Place the following steps for caring for a patient during a clinical experience in the correct order (Use the following format: 1, 2, 3, 4).
1. Evaluate care plan.
2. Implement interventions.
3. Evaluate nursing diagnoses.
4. Meet and assess the patient.

Question 34

A(n) ____________________ goal is not expected to be met before a patient is discharged from the hospital. It may be an ongoing process of improvement or a gradual change in circumstances.

Question 35

A nursing instructor is explaining the initial steps of most nursing interventions. The instructor recognizes that additional explanation is required when a student nurse states:

A) "You should always check the chart to be certain of a physician's or other health-care provider's order."
B) "You should always carry out the physician's order as quickly as possible without question."
C) "You should always explain the procedure to the patient using words the patient understands."
D) "You should always think critically about the order to make sure the patient's condition has not changed in such a way that the order might no longer be appropriate."

Question 36

Before the implementation of any ____________________, a nurse must be sure that he or she knows how to perform it. A nurse must always follow facility policy and practice within the scope established by the state's Nurse Practice Act.

Question 37

When a nurse enters a patient's room or area to perform a nursing interview, he first establishes ____________________, creating a relationship of mutual trust and understanding. The nurse does this by introducing himself and explaining his role in the patient's care.

Question 38

A nurse assesses a patient's urine and notices that it is dark yellow, concentrated, and lower in volume than normal. The nurse decides to put the patient on intake and output measurement because the patient has a risk for imbalanced fluid volume. This is an example of a(n)

A) Dependent intervention.
B) Indirect intervention.
C) Independent intervention.
D) Collaborative intervention.