Deck 23: The Nursing Process

Question 1

Ms.Dionne,56,has been having abdominal pain without any clear pathology for cause.The x-rays are normal,and there had been no recent trauma.Which of the following is the most appropriately written nursing diagnosis for this client?

A)Pain due to unknown factors
B)Pain related to unknown etiology
C)Pain caused by psychosomatic condition
D)Pain manifested by client's report

Answer 1

Pain related to unknown etiology

Question 2

A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits.The most appropriate diagnosis for this client is which of the following?

A)Wellness diagnosis
B)Syndrome diagnosis
C)Risk nursing diagnosis
D)Actual diagnosis

Answer 2

Wellness diagnosis

Question 3

What is a useful technique for clustering data?

A)Critical pathways
B)Concept mapping
C)Inferencing
D)Priority setting

Answer 3

Concept mapping

Question 4

Hannah,17,is quiet,pale,diaphoretic,and restless in her hospital bed.As the nurse is gathering data,Hannah says,"just leave me alone." Which of the following is subjective data?

A)Restless
B)"Just leave me alone"
C)Quiet
D)Pale and diaphoretic

Question 5

A client with a non-life-threatening wound to his hand comes into a very busy and crowded emergency department.What is the best way for the nurse to conduct an interview with this client?

A)Have the client wait until the department quiets down,since the wound is not too serious
B)Conduct the client interview in the waiting room
C)Draw curtains around the client and nurse to provide as much privacy as possible
D)Ensure that the client's back is to the rest of the room so as not to be heard by others

Question 6

A nurse makes the decision to look at wound care alternatives for Mr.Cutcliffe,87,who has a stasis ulcer that has not improved over the past two weeks.This represents which phase of the nursing process?

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

Question 7

A nurse is providing a back rub to a client immediately after administering a pain medication,with the hope that these two actions will help decrease the client's pain.This is an example of which phase of the nursing process?

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

Question 8

A nursing diagnosis of fluid volume deficit,related to active fluid loss,secondary to diarrhea has been formulated for a client.An appropriately written goal statement for this diagnosis would be which of the following?

A)Client will drink more fluids by tomorrow.
B)Skin turgor will be within normal limits.
C)Mucus membranes will be moist.
D)Client will have intake of at least 1000 mL within 24 hours.

Question 9

What type of data,also known as signs,are detectable by an observer?

A)Subjective
B)Variable
C)Constant
D)Objective

Question 10

Neena,15 months,has been admitted to the pediatric unit.Her parents are worried and upset,and her grandmother is also present.In this situation,what/who would be the best source of data?

A)Neena's birth record
B)Neena's parents
C)Grandmother,as the parents are upset
D)The admitting physician

Question 11

A nursing student does not understand the difference between evaluation and assessment.In order to differentiate between the two,what should the student remember?

A)Assessment is done at the beginning of the process.
B)They are the same and there is no need to differentiate.
C)Assessment is completed at the end of the process.
D)The difference is in how the data are used.

Question 12

While setting up for a procedure,an operating room nurse notices that the client has become unresponsive and respirations have become shallow.What type of assessment would be necessary in this situation?

A)Initial assessment
B)Problem-focused assessment
C)Emergency assessment
D)Time-lapsed assessment

Question 13

Mr.Vallente,32,was admitted just prior to the shift change.The oncoming nurse asks him many of the same questions as did the previous nurse.Mr.Vallente asks,"Why don't you people quit asking the same things over and over?" Which one of the following is the best response by the nurse?

A)"In order to make sure all of your information is complete,I need to ask these questions."
B)"You are right.Let me know if there is anything you need right now."
C)"I will be done shortly,just give me a few more minutes."
D)"Getting upset is not helpful.We are just doing our jobs."

Question 14

A student nurse understands that clustering data comes with experience and recognizing cues.What is the best way to recognize patterns or cues in the data?

A)Depend on knowledge gained from peers' experiences
B)Work with experienced nurses and learn from them
C)Take assessment notes and utilize information from textbooks
D)Know that this will take time,and experience is the best teacher

Question 15

A client has been admitted for acute dehydration,secondary to nausea and diarrhea.When is the best time for the nurse to conduct this client's interview?

A)As soon as the client arrives at the nursing unit
B)After the client has been oriented to the room
C)When the family is available to help
D)After the client has been medicated

Question 16

A client has been seeing a nurse practitioner for counselling following a rape.A long-term goal for this client would be which of the following?

A)Client will devise a list of phone numbers for support people.
B)Client will be able to share feelings of fear with counsellor.
C)Client will return to level of purpose and functioning as before the rape.
D)Client will state signs and symptoms of physical trauma.

Question 17

A goal statement in a client's care plan states: Client will have clear lung sounds bilaterally within three days.One of the interventions is to teach the client to cough and deep breathe every 2 hours.By the third day,the client's lungs are clear.To relate the intervention to the outcome,what should the nurse do?

A)Ask how many times per day the client practiced the coughing and deep breathing exercises
B)Tell the client that the lungs are clear
C)Document the assessment findings to show the effectiveness of the intervention
D)Write this evaluation statement: Goal met,lung sounds clear by third day

Question 18

Mr.Svendsen,74,has just been diagnosed with pancreatic cancer,and is upset and pacing around the room.The nurse has formulated the following diagnosis: Anxiety,related to unfamiliarity of disease process,manifested by restlessness and tachycardia.What is the etiology of this diagnosis?

A)Unfamiliarity of disease process
B)Anxiety
C)Restlessness
D)Tachycardia

Question 19

A nurse notices that there is a new area of skin breakdown near the site of a client's dressing.It appears to be caused from the tape used to secure the dressing.This would be an example of which phase of the nursing process?

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

Question 20

The nurse designs a nursing diagnosis of activity intolerance related to decreased airway capacity for a client with chronic asthma.She realizes that the client's vast knowledge about the disease serves as a coping skill.Why should the nurse utilize this information?

A)Strengths can be an aid to mobilizing health and the healing process.
B)The client will be more active in the plan.
C)It will be easier to educate the client about other interventions.
D)The client will need only minimal teaching about the pathology of the disease.

Question 21

The goal statement for a client's care plan reads as follows: Client will be able to state two positive aspects of rehab therapy by the end of the week.Which of the following is an appropriately written evaluation statement?

A)Goal incomplete: client not able to positively state anything about rehabilitation.
B)Goal met: client able to state one positive aspect by the end of the week.
C)Goal met: client able to state two positive aspects of therapy by week's end.
D)Goal not met: client able to state one positive aspect by the end of the week.

Question 22

Which of the following is a true statement about quality improvement?

A)Quality improvement focuses on ensuring that standards of care are met.
B)Improving the well-being of patients is the goal of quality improvement.
C)Quality improvement focuses on how patient care is provided,not the person providing care.
D)Relating organizational structure to the patient care is the aim of quality improvement.

Question 23

What is one of the main purposes of the evaluation phase of the nursing process?

A)Validate and organize data
B)Analyze data and recognize strengths
C)Relate nursing actions to client goals/outcomes
D)Reassess the client and document nursing activities

Question 24

Mrs.Wu,48,has terminal cancer and has this nursing diagnosis: Pain related to neuromuscular involvement of disease process.The goal statement is as follows: Client will be free of pain within 48 hours.As an intervention,the nurse will administer narcotic analgesics.What is the flaw in this plan?

A)The goal statement is written inaccurately.
B)The interventions are dependent on nursing.
C)The goal is unrealistic.
D)The interventions are not clear enough.

Question 25

When implementing a care plan,the nurse involves a client who is ready for discharge in the planning.One of the goals is that the client will have improved mobility.Which of the following might be an appropriate desired outcome statement for this goal?

A)Client will ambulate without a walker by 6 weeks.
B)Client will ambulate freely in his house.
C)Client will not fall.
D)Client will have freer movement in daily activities.

Question 26

A client had an outcome goal stated as follows: Client will have a decrease in pain level (down to a 3)within 45 minutes of receiving oral analgesic.Which statement by the client will the nurse use to evaluate this goal?

A)"The medication is making me sleepy."
B)"I think my pain level is a 4."
C)"I still have some pain."
D)"Will the pain ever go away?"

Question 27

Several types of audits (examination of records)are conducted in health care environments.Which of the following audits would be appropriately used to review a client's health while the client is still in hospital?

A)Concurrent
B)Peer review
C)Quality improvement
D)Retrospective

Question 28

A client who has been in a wheelchair for several years is experiencing skin breakdown,urinary retention,as well as bouts of depression.When considering nursing diagnoses,an appropriate selection would be which of the following?

A)Risk diagnosis
B)Syndrome diagnosis
C)Actual diagnosis
D)Wellness diagnosis