Deck 9: Nursing Process

Question 1

A patient is admitted to the hospital after a motorcycle accident.The nurse in the emergency room is assessing vital signs,general appearance and behavior,and performing a head-to-toe examination of all body systems.What is the nurse doing?

A) Making a medical diagnosis
B) Performing a physical examination
C) Making an evaluation
D) Performing data validation

Answer 1

Performing a physical examination

Question 2

A nurse is interviewing a patient being admitted to the hospital for surgery.During the interview,the nurse introduces self and explains that will be gathering some information.The nurse is in which phase of the interview?

A) Orientation
B) Working
C) Assessment
D) Termination

Answer 2

Orientation

Question 3

A 2-year-old patient is being admitted to the outpatient surgery for a tonsillectomy.Which will provide the best primary source of information for what comforts the patient when stressed?

A) Patient chart
B) Patient
C) Parents
D) Surgeon

Answer 3

Parents

Question 4

A mother of five children is admitted to the hospital for abdominal pain.The nurse asks a series of questions before performing a physical assessment.The patient answers the questions.When asking the patient some other questions,the patient's spouse starts to answer.As the admission process progresses and the nurse gathers subjective data,the nurse requests that the patient answer the next questions.What is the rationale for the nurse's behavior?

A) The patient is exhibiting confusion.
B) The spouse is being obnoxious.
C) The patient is the best source of information.
D) The spouse is too controlling.

Question 5

A nurse is collecting data during the assessment of a patient.During the assessment,the nurse collects both subjective and objective data.Which information should the nurse consider as subjective data?

A) Heart rate of 96
B) Incisional erythema
C) Emesis of 150 mL
D) Sharp, burning pain

Question 6

Which action by the nurse is the final step in a complete assessment?

A) Forming diagnostic conclusions
B) Documentation of findings
C) Auscultation
D) Palpation

Question 7

A postoperative patient has denied the need for pain medication.The nurse has noted that the patient describes the pain as a "1" on a 0 to 10 scale.The nurse also notes that the patient grimaces when he or she changes position and guards the incision.The nurse believes that the patient is experiencing pain based on the information gathered in the assessment.What is this phenomenon known as?

A) Cue
B) Inference
C) Diagnosis
D) Health pattern

Question 8

The nurse is admitting a patient to the unit and asks the patient about the health history.The nurse is engaged in which component of the nursing process?

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

Question 9

The nurse has just completed an assessment on a patient with a fractured right femur.Which data will the nurse categorize as objective?

A) The patient's toes of right foot are warm and pink.
B) The patient reports a dull ache in the right hip.
C) The patient says feels tired all the time.
D) The patient is concerned about insurance coverage.

Question 10

A nurse is teaching the staff about the phases of the interview process.Which information should the nurse include in the teaching session?

A) Orientation, working, termination
B) Orientation, assessment, evaluation
C) Planning, assessment, termination
D) Planning, assessment, evaluation

Question 11

A nurse wants to provide patient-centered care to a patient of another culture.Which question is the most culturally sensitive when talking about a patient's illness?

A) "What do you call your problem?"
B) "How long has your child had the runs?"
C) "When did you last void today?"
D) "Has anyone else in your family had diarrhea?"

Question 12

Which question or comment should the nurse initially use that would best gather the most information during a health history assessment?

A) "Let us help you."
B) "Did you seek help when it first started?"
C) "Tell me about the problems you are having."
D) "Do you have a family history of this problem?"

Question 13

A patient with a history of seizures is being admitted to the hospital after a grand mal seizure took place at a shopping mall.The patient's spouse accompanied the patient to the hospital and is being interviewed by the nurse.Which question should the nurse ask to quickly focus on the patient's symptoms?

A) "What made you choose this hospital?"
B) "How long did the seizure last?"
C) "Tell me how the seizure disorder has affected the family."
D) "Tell me why you brought your spouse to the hospital today."

Question 14

A nurse is collecting data on a patient who is being admitted into hospice care.The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained.The nurse is currently involved in which step of the nursing process?

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

Question 15

A 67-year-old male patient of French heritage is admitted to the hospital.The patient is interviewed by a nurse from a Korean family.The nurse did not make eye contact with the patient while conducting the interview.This disturbed the patient because the patient thought that the nurse might be trying to hide something.Which factor most likely influenced the behavior of the nurse and patient?

A) Culture
B) Validation
C) Collaborative problem
D) Defining characteristics

Question 16

A patient with bilateral pneumonia is admitted to the intensive care unit.The nurse who initially prepared the plan of care identified that the patient had the collaborative problem of Potential complications: hypoxemia.What made the nurse classify this as a collaborative problem?

A) It requires ensuring adequate hydration.
B) It requires monitoring for signs of acid-base imbalance.
C) It requires evaluating the effects of positioning on oxygenation.
D) It requires both nursing and physician-prescribed interventions.

Question 17

A postoperative patient is continuing to have incisional pain.As part of the nurse's assessment,the nurse notes that the patient is grimacing when he or she changes position.The patient's grimace can be useful in the assessment and can be described as which of the following?

A) Cue
B) Inference
C) Diagnosis
D) Health pattern

Question 18

When admitting a patient to the hospital,the nurse asks if has problems eating since the patient had a stroke.The patient denies any problems and states that does not require assistance.After lunch,the nurse notes that the patient has not eaten most of the food and has spilled much of the food.These cues lead the nurse to believe that the patient is not functioning at the level indicated upon admission.The nurse is using which type of information to make this deduction?

A) Verbal behavior
B) Physical assessment
C) Nursing diagnosis
D) Nonverbal behavior

Question 19

A student nurse is responsible for assessing a patient,who is abrupt and requests that the assessment be done later by a nurse.As the student nurse charts the interaction,which statement is the best way to document what happened?

A) Appears to be in pain as evidenced by grouchy behavior
B) Behavior is inappropriate, requests registered nurse do the assessment
C) States, "I want a registered nurse to do my assessment"
D) Is grumpy, registered nurse notified

Question 20

As a nurse is obtaining a health history from a patient,the nurse uses comments such as "go on." Which technique is the nurse using?

A) Cues
B) Inferences
C) Back-channeling
D) Termination

Question 21

A patient has an outcome of ambulating three times a day.The patient does not ambulate the entire day.What should the nurse do next?

A) Walk the patient.
B) Reassess the patient.
C) Change the goal for the patient.
D) Continue with the plan for the patient.

Question 22

The nurse is beginning an assessment of a newly admitted patient.What are some recommended comprehensive assessment approaches the nurses can use? (Select all that apply.)

A) Functional Health Patterns
B) Nursing Diagnosis
C) Problem-Focused Approach
D) Nursing Intervention Classification
E) Nursing Outcome Classification

Question 23

A nurse is delegating care of patients to the nursing assistant personnel (NAP)and a licensed practical nurse (LPN).Which situation indicates the nurse needs more instruction on delegation?

A) LPN to change a sterile dressing
B) NAP to provide skin care
C) NAP to insert an indwelling catheter
D) LPN to administer an enema

Question 24

A nurse is caring for a patient and performs several interventions.Which action by the nurse is an independent nursing intervention?

A) Turning every 2 hours
B) Administering a medication
C) Inserting an indwelling catheter
D) Starting an intravenous (IV) for intravenous fluids

Question 25

A patient has met the goals and outcomes mutually agreed upon for improvement of ventilatory status.What should the nurse do next?

A) Modify the care plan.
B) Discontinue the care plan.
C) Create a nursing diagnosis that states goals have been met.
D) Reassess the patient's response to care and evaluate interventions.

Question 26

A nurse is evaluating care for a patient.Which action should the nurse take?

A) Compares patient findings with the goals and outcomes
B) Determines if interventions were completed
C) Develops a nursing diagnosis
D) Writes a care plan

Question 27

A patient has lost 10 pounds in the last 2 months from breast cancer and chemotherapy.The chemotherapy has caused the patient to not eat.Which nursing diagnosis should the nurse use to develop the plan of care?

A) Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Food Intake
B) Imbalanced Nutrition: Less Than Body Requirements Related to Cancer
C) Imbalanced Nutrition: Less Than Body Requirements Related to Loss of Weight
D) Imbalanced Nutrition: Less Than Body Requirement Related to Insufficient Prescription of Chemotherapy

Question 28

A nurse is writing a care plan for a newly admitted patient.Which outcome statement did the nurse correctly write?

A) "The patient will eat 80% of all meals."
B) "The nursing assistant will set up the patient for a bath every day."
C) "The nursing assistant will ambulate the patient three times a day by May 30."
D) "The patient will identify the need to increase dietary intake of fiber by July 4."

Question 29

Upon assessment,the nurse finds that a patient has a heart rate of 66 beats per minute,a respiratory rate of 12 breaths per minute,and a blood pressure of 120/80 mm Hg.The nurse obtained which type of data?

A) Personal
B) Demographic
C) Subjective
D) Objective

Question 30

A patient states,"I'm burning up,and I have a fever." The nurse takes the patient's temperature,observes the skin for flushing,and feels the skin temperature.This is an example of __________ subjective data.

A) validating
B) clustering
C) reviewing
D) documenting

Question 31

A home health nurse is providing care to a patient.Which action by the nurse is a physical care technique?

A) Dressing a patient
B) Assisting a patient to learn how to shop
C) Performing range-of-motion exercises
D) Administering cardiopulmonary resuscitation

Question 32

A patient is suffering from shortness of breath.How should the nurse write the expected outcome for this patient?

A) "The patient will be comfortable by the morning."
B) "The patient will breathe unlabored at 14 to 18 breaths per minute by the end of the shift."
C) "The patient will not complain of breathing problems."
D) "The patient will appear less short of breath."

Question 33

A nurse develops a nursing diagnosis for a patient.What is the rationale for the nurse's actions?

A) It allows a nurse to compete with physicians or health care providers.
B) It allows a nurse to develop an individualized plan of care.
C) It allows a nurse to treat nursing problems and medical problems.
D) It allows a nurse to manage patient care for the entire health team.