Deck 13: Nursing Assessment, diagnosis, and Planning

Question 1

Which of the following methods of data collection is utilized to establish a patient's nursing database?

A)Reviewing the current literature to determine evidence-informed nursing actions.
B)Orders for diagnostic and laboratory tests.
C)Physical examination.
D)Anticipated medications to be ordered.

Answer 1

Physical examination.

Question 2

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse

A)Completes a comprehensive database.
B)Identifies pertinent nursing diagnoses.
C)Intervenes on the basis of patient goals and priorities of care.
D)Determines whether outcomes have been achieved.

Answer 2

Completes a comprehensive database.

Question 3

Which patient outcome statement includes all seven guidelines for writing goal and outcome statements?

A)The patient will ambulate in hallways.
B)The nurse will administer pain medication every 4 hours to keep the patient free from discomfort.
C)The nurse will monitor the patient's heart rhythm continuously this shift.
D)The patient will feed self at all mealtimes today without complaints of shortness of breath.

Answer 3

The patient will feed self at all mealtimes today without complaints of shortness of breath.

Question 4

While interviewing an older female patient of Asian descent,the nurse notices that the patient looks at the ground when answering questions.What should this nurse do?

A)Notify the physician to recommend a psychological evaluation.
B)Consider cultural differences during this assessment.
C)Ask the patient to make eye contact to determine her affect.
D)Continue with the interview and document that the patient is depressed.

Question 5

After reviewing the interview process and objectives during a patient-centred interview,what will the nurse do?

A)Begin by introducing himself or herself.
B)Document a nursing health history.
C)Explain that the interview will be over in a few more minutes.
D)Tell the patient that he'll be back to administer medications in 1 hour.

Question 6

Subjective data include which of the following?

A)A patient's feelings,perceptions,and reported symptoms.
B)A description of the patient's behaviour.
C)Observations of a patient's health status.
D)Measurements of a patient's health status.

Question 7

When planning patient care,a goal can be described as which of the following?

A)A statement describing the patient's accomplishments without a time restriction.
B)A realistic statement predicting any negative responses to treatments.
C)A broad statement describing a desired change in patient behaviour.
D)An identified long-term nursing diagnosis.

Question 8

Which of the following options correctly explains what the nurse should do with the plan of care for a patient after it is developed?

A)Place the original copy in the chart,so it cannot be tampered with or revised.
B)Communicate the plan of care to all health care providers involved in the patient's care.
C)Send the plan of care to the administration office to be filed.
D)Send the plan of care to quality assurance for review.

Question 9

Which of these outcomes would be most appropriate for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications?

A)Patient will have one soft,formed bowel movement by end of shift.
B)Patient will not take any pain medications this shift.
C)Patient will walk unassisted to bathroom by the end of shift.
D)Patient will not take laxatives or stool softeners this shift.

Question 10

The following statements are part of a patient's nursing care plan.Which of the following statements represents an expected outcome?

A)The patient will verbalize a decreased pain level less than 3 on a 0-to-10 scale by the end of this shift.
B)The patient will demonstrate increased mobility in 2 days.
C)The patient will demonstrate increased tolerance of activity over the next month.
D)The patient will understand needed dietary changes by discharge.

Question 11

A patient's plan of care includes the goal of increasing mobility this shift.As the patient is ambulating to the bathroom at the beginning of the shift,the patient suffers a fall.How should the nurse first revise the plan of care?

A)Asking physiotherapy to assist the patient because of the new injuries.
B)Disregarding all previous diagnoses and establishing a new plan of care.
C)Reassessing the patient.
D)Setting new priorities for the patient.

Question 12

A patient's son decides to stay at the bedside while his father is confused.When developing the plan of care for this patient,what should the nurse do?

A)Individualize the care plan only according to the patient's needs.
B)Request that the son leave at bedtime,so the patient can rest.
C)Suggest that a female member of the family stay with the patient.
D)Involve the son in the plan of care as much as possible.

Question 13

After completing a thorough database review and analyzing the data to identify any problems,the nurse should proceed to what step of the nursing process?

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

Question 14

To gather information about a patient's home and work surroundings,the nurse will need to utilize which method of data collection?

A)Carefully review laboratory results.
B)Conduct the physical assessment before collecting subjective information.
C)Document a thorough nursing health history.
D)Prolong the termination phase of the interview.

Question 15

A nursing assessment for a patient with a spinal cord injury reveals several pertinent problems that a nurse can treat.While the plan of care is developed,which nursing diagnosis is the highest priority for this patient?

A)Risk for impaired skin integrity.
B)Risk for infection.
C)Spiritual distress.
D)Reflex urinary incontinence.

Question 16

What is the purpose and distinction of using a concept map when a plan of care is implemented?

A)Quality assurance in the health care facility.
B)Multidisciplinary communication.
C)Provision of a standardized format for patient problems.
D)Identification of the relation of patient problems and interventions.

Question 17

A patient expresses fear of going home and being alone.Her vital signs are stable and her incision is nearly completely healed.The nurse can infer from the subjective data that

A)The patient can now perform the dressing changes herself.
B)The patient can begin retaking all her previous medications.
C)The patient is apprehensive about discharge.
D)Surgery was not successful.

Question 18

The nurse is working with a patient who is being prepared for a diagnostic test this afternoon.The patient tells the nurse that she wants to have her hair shampooed.Which of the following is the most appropriate label with regard to assigning a priority for the patient's request?

A)Low priority.
B)An unmet need.
C)Intermediate priority.
D)A safety and security need.

Question 19

When evaluating a plan of care,the nurse reviews the goals for the patient.Which goal statement is realistic for a patient with a pelvic fracture on bed rest?

A)The patient will increase mobility by ambulating in the hallway two times this shift.
B)The patient will increase mobility by turning side to back to side with assistance every 2 hours.
C)The patient will increase mobility by using the walker correctly to ambulate to the bathroom as needed.
D)The patient will increase mobility by using a sliding board correctly to transfer to the bedside commode as needed.

Question 20

The nurse is caring for seven patients this shift.After completing their assessments,the nurse states that he doesn't know where to begin in developing care plans for these patients.Which of the following is an appropriate suggestion by another nurse?

A)"Choose all the interventions and perform them in order of time needed for each one."
B)"Make sure you identify the scientific rationale for each intervention first."
C)"Decide on goals and outcomes you have chosen for the patients."
D)"Begin with the highest priority diagnoses,and then select appropriate interventions."

Question 21

Which of the following are examples of subjective data? (Select all that apply. )

A)Patient describing excitement about discharge.
B)Patient's wound appearance.
C)Patient's expression of fear regarding upcoming surgery.
D)Patient pacing the floor while awaiting test results.
E)Patient's temperature.

Question 22

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed.What is the nurse's best action in response to her observation?

A)Proceed to the next patient's room while making rounds.
B)Offer a massage because the patient does not want any more pain medicine.
C)Administer the pain medication ordered for moderate to severe pain.
D)Ask the patient about the facial grimacing with movement.

Question 23

The nurse is attempting to prompt the patient to elaborate on her complaints of daytime fatigue.Which question should the nurse ask?

A)"Is there anything that you are stressed about right now?"
B)"What reasons do you think are contributing to your fatigue?"
C)"What are your normal work hours?"
D)"Are you sleeping 8 hours a night?"

Question 24

A nurse comparing data validation and data interpretation correctly explains the difference with which statement?

A)"Validation involves looking for patterns in professional standards."
B)"Data interpretation involves discovering patterns in professional standards."
C)"Validation involves comparing data with other sources for accuracy."
D)"Data interpretation occurs before data validation."

Question 25

A nursing student is completing an assessment on an 80-year-old patient who is alert and oriented.The patient's daughter is present in the room.Which of the following actions made by the nursing student requires the nursing professor to intervene?

A)The nursing student is making eye contact with the patient.
B)The nursing student is speaking only to the patient's daughter.
C)The nursing student nods periodically while the patient is speaking.
D)The nursing student leans forward while talking with the patient.

Question 26

While the patient's lower extremity,which is in a cast,is assessed,the patient tells the nurse about an inability to rest at night.The nurse disregards this complaint,thinking that no correlation has been noted between having a leg cast and developing restless sleep.What would be a more theoretically sound first approach?

A)Document the sleep patterns and complaint in the patient's chart.
B)Tell the patient you are just focused on the leg right now.
C)Explain that a more thorough assessment will be needed next shift.
D)Ask the patient about his usual sleep patterns and when the difficulty with resting began.

Question 27

While completing an admission database,the nurse is interviewing a patient who states that he is allergic to latex.What is the most appropriate first nursing action?

A)Leave the room and place the patient in isolation.
B)Ask the patient to describe the type of reaction.
C)Proceed to the termination phase of the interview.
D)Document the latex allergy on the medication administration record.

Question 28

The nurse is assessing a patient with a hearing deficit.Where is the best place to conduct this interview?

A)The patient's room with the door closed.
B)The waiting area with the television turned off.
C)The patient's room before administration of pain medication.
D)The patient's room while the occupational therapist is working on leg exercises.

Question 29

Components of a nursing health history include

A)Current treatment orders.
B)Nurse's concerns.
C)Nurse's goals for the patient.
D)Patient expectations.