Deck 5: Introduction to the Nursing Process

Question 1

The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a patient scheduled for back surgery. Which step of the nursing process is the nurse addressing?

A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation

Answer 1

Implementation

Question 2

In which step of the nursing process does the nurse prioritize the nursing diagnoses and identify interventions to address the patient goals?

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

Answer 2

Planning

Question 3

A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. The nurse asks the manager if there is a document written by the physician for this type of reaction. The nurse is referring to a:

A) protocol.
B) clinical pathway.
C) standing order.
D) care map.

Answer 3

standing order.

Question 4

The nurse is admitting a patient experiencing chest discomfort and shortness of breath. The patient also has a history of stroke. The nurse documents the nursing diagnosis "Risk for stroke related to history of stroke." The risk factor for this patient is:

A) stroke.
B) history of stroke.
C) chest discomfort.
D) shortness of breath.

Question 5

The nurse is completing the health history on a patient admitted for cardiac rehabilitation. The health history is conducted in which step of the nursing process?

A) Assessment
B) Diagnosis
C) Implementation
D) Evaluation

Question 6

The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The essential step that was added in 1991 is:

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

Question 7

The nurse is caring for a patient diagnosed with Lyme disease. The patient tells the nurse, "My heart seems to be skipping some beats. My doctor told me to let the nurse know if this happens since it might be a complication of my disease." The nurse auscultates the heart and confirms the palpitations. Which step of the nursing process does the nurse's action demonstrate?

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

Question 8

The nursing process is the foundation of professional nursing practice. As such, the nursing process can be defined as:

A) The framework that nurses used to provide care.
B) A complex process during which nurses think about their thinking.
C) The process that allows nurses to collect essential data.
D) Thinking like a nurse in developing plans of care.

Question 9

During a patient's bath, the nurse observes the patient having a tonic clonic seizure. The nurse immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of the nursing process?

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

Question 10

Which of the following is a correctly written nursing diagnosis appropriate for a patient's plan of care?

A) Ineffective airway clearance related to excessive secretions as evidenced by diminished breath sounds.
B) Imbalanced nutrition: less than body requirements.
C) Impaired physical mobility related to contractures.
D) Risk for suffocation related to smoking in bed as evidenced by absent breath sounds.

Question 11

The community health nurse is applying the nursing process to the care of patients with coronary artery disease. The nurse determines that most of the patients eat high-fat meals from the local fast-food restaurant and plans a nutrition workshop. The nurse is applying the nursing process characteristic of:

A) organization.
B) dynamics.
C) adaptability.
D) collaboration.

Question 12

The charge nurse is discussing a patient's care plan during a team meeting. The team determines that the patient has not met the goal of "ambulating to the nurse's station twice a day" and decides to revise the plan. Which of the following characteristics of the nursing process most represents this decision?

A) Organization
B) Dynamics
C) Adaptability
D) Outcome orientation

Question 13

The nurse writes a short-term goal for a patient scheduled for surgery in the morning. The goal that contains all of the necessary elements is:

A) The patient will walk to the bathroom within 48 hours after surgery.
B) The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery.
C) The patient will walk to the bathroom without experiencing shortness of breath.
D) The patient will walk to the bathroom without experiencing shortness of breath after surgery.

Question 14

A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process?

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

Question 15

The nurse is caring for a patient who will be discharged home following surgical repair of a broken shoulder. The patient tells the nurse, "I don't have anyone at home who can help me cook my meals. Is there something you can do?" Demonstrating the adaptability of the nursing process, the nurse should:

A) adjust the patient's care plan so that nursing goals can be met.
B) consult the care provider about extending the patient's hospitalization.
C) abandon the plan of care as not able to be done.
D) contact the social worker about community services.

Question 16

The nursing process is cyclic rather than linear. Because of the cyclic nature, as an individual patient's condition changes:

A) The nurse's thought processes do not have to vary.
B) Plans of care are easier to use and do not need modification.
C) The accuracy and effectiveness of thought processes must be considered.
D) Reflective thought is not necessary since issues tend to be repetitive.

Question 17

All nursing interventions that are implemented for patients must be documented or charted. Proper documentation of interventions:

A) facilitates communication with all members of the health care team.
B) are only considered "legal" if documented in the paper chart.
C) leads to errors of omission and repetition of care.
D) does not directly measure goal achievement or outcomes.

Question 18

The nursing student is caring for a patient admitted with severe anemia. The patient receives two units of packed red blood cells and tells the student, "I am feeling so much better. I'm not so tired anymore and can bathe myself." The student reviews the patient goal "report an increase in activity tolerance" and concludes that the patient's goal has been met and adjusts the patient's plan of care. This is an example of nursing process:

A) organization.
B) dynamics.
C) adaptability.
D) collaboration.

Question 19

The nurse makes the following entry on the patient's care plan: "Goal not met. Patient refuses to walk and states, 'I'm afraid of falling.'" The nurse should:

A) ignore the patient's concern in evaluating goal attainment.
B) document the patient's unwillingness to continue the plan of care.
C) continue the plan of care as originally agreed upon.
D) modify the care plan in response to the patient's condition and wishes.

Question 20

The nurse is assisting a patient to bed when the patient says, "My chest hurts and my left arm feels numb. What's wrong with me?" What is the type and source of data obtained from the patient's complaint?

A) Objective data from a primary source
B) Objective data from a secondary source
C) Subjective data from a primary source
D) Subjective data from a secondary source

Question 21

The nurse develops a list of nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, "I understand that I will lose most of my hair. Will it grow back?" Which of the following diagnoses will have the highest priority?

A) Disturbed body image
B) Nausea
C) Risk for bleeding
D) Imbalanced nutrition: less than body requirements

Question 22

Establishing short- and long-term goals to address nursing diagnoses involves: (Select all that apply.)

A) discussion with the patient.
B) exclusion of family with making patient decisions.
C) collaboration with other members of health care team.
D) making the health care provider as the central figure.
E) coordination of care as collaborative care.

Question 23

The nurse is attempting to develop nursing diagnoses for her patient. The nurse understands that nursing diagnoses: (Select all that apply.)

A) identify actual or potential problems as well as responses to a problem.
B) require naming patient problems using nursing diagnostic labels.
C) utilize objective data since subjective data are often inaccurate.
D) includes unvalidated data to determine an accurate and thorough diagnosis.
E) are similar to medical diagnoses since they both are labels for diseases.

Question 24

Which of the following statements would be considered objective data? (Select all that apply.)

A) "I'm short of breath."
B) "Blood pressure 90/68, apical pulse 102, skin pale and moist."
C) "Lung sounds clear bilaterally, diminished in right lower lobe."
D) "I feel weak all over when I exert myself."
E) "My pain level is down to 2. It was 8."

Question 25

The nurse is gathering data on a patient with acute bacterial pneumonia. This is an example of which step of the nursing process?

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