Question 1

What is classified as information provided by the family when a patient is unable to provide data during assessment?

Accepted Answer

A)  Primary 
B)  Secondary 
C)  Unreliable 
D)  Biased 
A)  Primary 
B)  Secondary 
C)  Unreliable 
D)  Biased

Question 2

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

Accepted Answer

A)  The patient complains of chest pain. 
B)  The patient states, "I feel nauseous." 
C)  The patient complains of feeling faint. 
D)  The patient is short of breath on exertion. 
A)  The patient complains of chest pain. 
B)  The patient states, "I feel nauseous." 
C)  The patient complains of feeling faint. 
D)  The patient is short of breath on exertion.

Question 3

What is an example of an appropriate nursing diagnosis?

Accepted Answer

A)  Constipation 
B)  Patient complains of constipation 
C)  Need for laxatives 
D)  Patient has a duodenal ulcer 
A)  Constipation 
B)  Patient complains of constipation 
C)  Need for laxatives 
D)  Patient has a duodenal ulcer

Question 4

From where are the "risk for" nursing diagnoses identified?

Accepted Answer

A)  The care plan 
B)  The interventions 
C)  The assessment 
D)  The evaluation 
A)  The care plan 
B)  The interventions 
C)  The assessment 
D)  The evaluation

Question 5

What subjective data does the nurse record following a head-to-toe examination?

Accepted Answer

A)  Rash on back 
B)  Prolonged nausea 
C)  Blood pressure of 190/100 
D)  White blood cell count of 19,000 
A)  Rash on back 
B)  Prolonged nausea 
C)  Blood pressure of 190/100 
D)  White blood cell count of 19,000

Question 6

What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions?

Accepted Answer

A)  The patient will increase intake to 1000 mL daily to liquefy secretions. 
B)  The patient will cough more frequently within 3 days. 
C)  The patient will breathe better within 3 days. 
D)  The patient will perform deep-breathing exercises four times daily. 
A)  The patient will increase intake to 1000 mL daily to liquefy secretions. 
B)  The patient will cough more frequently within 3 days. 
C)  The patient will breathe better within 3 days. 
D)  The patient will perform deep-breathing exercises four times daily.

Question 7

Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) __________ __________ ____________.

Accepted Answer

risk nursing diagnosis
A risk

Question 8

A systemic, dynamic process by which the nurse, through interaction with the patient, significant others, and health care providers, collects and analyzes data about the patient is known as ______________________.

Accepted Answer

assessment
The American Nurses Associati

Question 9

All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment?

Accepted Answer

A)  53-year-old admitted with a perforated ulcer 
B)  5-year-old admitted for the implant of grommets in the middle ear 
C)  76-year-old admitted for a knee replacement 
D)  40-year-old admitted for possible bowel obstruction 
A)  53-year-old admitted with a perforated ulcer 
B)  5-year-old admitted for the implant of grommets in the middle ear 
C)  76-year-old admitted for a knee replacement 
D)  40-year-old admitted for possible bowel obstruction

Question 10

What is the primary purpose of nursing orders?

Accepted Answer

A)  To support physician's orders 
B)  To provide direction for all caregivers 
C)  To provide broad, general statements 
D)  To clarify nursing principles 
A)  To support physician's orders 
B)  To provide direction for all caregivers 
C)  To provide broad, general statements 
D)  To clarify nursing principles

Question 11

Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a _____________ ____________ ____________.

Accepted Answer

wellness nursing diagnosis
A w

Question 12

When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process?

Accepted Answer

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

Question 13

What are the two primary methods used to collect data?

Accepted Answer

A)  Written report by patient and family 
B)  Review of the chart and the nurse's notes 
C)  Interview and physical examination 
D)  Review of the physician's orders and the Kardex 
A)  Written report by patient and family 
B)  Review of the chart and the nurse's notes 
C)  Interview and physical examination 
D)  Review of the physician's orders and the Kardex

Question 14

What is an example of an appropriate nursing diagnosis?

Accepted Answer

A)  Impaired skin integrity 
B)  Skin breakdown noted 
C)  Turn patient every 2 hours 
D)  The patient has scabies on his back 
A)  Impaired skin integrity 
B)  Skin breakdown noted 
C)  Turn patient every 2 hours 
D)  The patient has scabies on his back

Question 15

What objective data should the nurse include after a patient assessment?

Accepted Answer

A)  Headache of 3 days duration 
B)  Severe stomach cramps 
C)  Flatulence 
D)  Anxiety 
A)  Headache of 3 days duration 
B)  Severe stomach cramps 
C)  Flatulence 
D)  Anxiety

Question 16

Which are considered phases of the nursing process? (Select all that apply.)

Accepted Answer

A)  Diagnosis 
B)  Prediction 
C)  Assessment 
D)  Evaluation 
E)  Implementation
F) Outcome identification 
A)  Diagnosis 
B)  Prediction 
C)  Assessment 
D)  Evaluation 
E)  Implementation
F) Outcome identification

Question 17

What documentation reflects implementation?

Accepted Answer

A)  "Patient selected low-sugar snacks independently." 
B)  "Patient was medicated with Tylenol 500 mg PO for pain." 
C)  "Patient was ambulated for 15 minutes after lunch." 
D)  "Patient participated in group therapy session without reminder." 
A)  "Patient selected low-sugar snacks independently." 
B)  "Patient was medicated with Tylenol 500 mg PO for pain." 
C)  "Patient was ambulated for 15 minutes after lunch." 
D)  "Patient participated in group therapy session without reminder."

Question 18

What assists the nurse in the identification of nursing diagnoses?

Accepted Answer

A)  Objective data 
B)  Subjective data 
C)  Data clustering 
D)  Validated data 
A)  Objective data 
B)  Subjective data 
C)  Data clustering 
D)  Validated data

Question 19

A nurse is formulating a nursing diagnosis. What is an example of an appropriately written nursing diagnosis?

Accepted Answer

A)  Risk for impaired skin integrity related to physical immobilization 
B)  Physical immobilization secondary to risk for impaired skin integrity 
C)  Risk for impaired skin integrity related to diagnosis of decubitus ulcers 
D)  Physical immobilization secondary to decreased cognitive ability 
A)  Risk for impaired skin integrity related to physical immobilization 
B)  Physical immobilization secondary to risk for impaired skin integrity 
C)  Risk for impaired skin integrity related to diagnosis of decubitus ulcers 
D)  Physical immobilization secondary to decreased cognitive ability

Question 20

A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases is known as a ___________ ____________.

Accepted Answer

critical pathway
A critical pa

Exam 5: Nursing Process and Critical Thinking

What is classified as information provided by the family when a patient is unable to provide data during assessment?

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

What is an example of an appropriate nursing diagnosis?

From where are the "risk for" nursing diagnoses identified?

What subjective data does the nurse record following a head-to-toe examination?

What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions?

Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) __________ __________ ____________.

A systemic, dynamic process by which the nurse, through interaction with the patient, significant others, and health care providers, collects and analyzes data about the patient is known as ______________________.

All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment?

What is the primary purpose of nursing orders?

Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a _____________ ____________ ____________.

When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process?

What are the two primary methods used to collect data?

What is an example of an appropriate nursing diagnosis?

What objective data should the nurse include after a patient assessment?

Which are considered phases of the nursing process? (Select all that apply.)

What documentation reflects implementation?

What assists the nurse in the identification of nursing diagnoses?

A nurse is formulating a nursing diagnosis. What is an example of an appropriately written nursing diagnosis?

A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases is known as a ___________ ____________.

Evolution of Nursing

Legal and Ethical Aspects of Nursing

Documentation

Communication

Cultural and Ethnic Considerations

Asepsis and Infection Control

Body Mechanics and Patient Mobility

Hygiene and Care of the Patient’s Environment

Safety

Vital Signs

Physical Assessment

Admission, Transfer, and Discharge

Surgical Wound Care

Specimen Collection and Diagnostic Testing

Care of Patients Experiencing Urgent Alterations in Health

Complementary and Alternative Therapies

Pain Management, Comfort, Rest, and Sleep

Nutritional Concepts and Related Therapies

Fluids and Electrolytes

Mathematics and Medication Administration

Care of Patients with Alterations in Health

Life Span Development

Loss, Grief, Dying, and Death

Health Promotion and Pregnancy

Labor and Delivery

Care of the Mother and Newborn

Care of the High-Risk Mother, Newborn, and Family with Special Needs

Health Promotion for the Infant, Child, and Adolescent

Basic Pediatric Nursing Care

Care of the Child with a Physical and Mental or Cognitive Disorder

Health Promotion and Care of the Older Adult

Concepts of Mental Health

Care of the Patient with a Psychiatric Disorder

Care of the Patient with an Addictive Personality

Home Health Nursing

Long-Term Care

Rehabilitation Nursing

Hospice Care

Introduction to Anatomy and Physiology

Care of the Surgical Patient

Care of the Patient with an Integumentary Disorder

Care of the Patient with a Musculoskeletal Disorder

Care of the Patient with a Gastrointestinal Disorder

Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder

Care of the Patient with a Blood or Lymphatic Disorder

Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder

Care of the Patient with a Respiratory Disorder

Care of the Patient with a Urinary Disorder

Care of the Patient with an Endocrine Disorder

Care of the Patient with a Reproductive Disorder

Care of the Patient with a Sensory Disorder

Care of the Patient with a Neurologic Disorder

Care of the Patient with an Immune Disorder

Care of the Patient with HIV/AIDS

Care of the Patient with Cancer

Professional Roles and Leadership

Filters

Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) ____.

Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a _ .

A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases is known as a _ __.