Exam 5: Introduction to the Nursing Process

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

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?

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

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

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:

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

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?

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:

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

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 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?

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

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:

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?

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?

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

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:

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

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:

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