Deck 4: The Use of the Nursing Process and Nursing Diagnosis

Question 1

The nurse is identifying interventions for an older patient's plan of care. Why should the nurse ask the certified nursing assistants (CNAs) to help develop these interventions?
1) They are nicer to the resident.
2) They spend the most time with the resident.
3) They have the most theory-based knowledge.
4) They are better received by the family members.

Answer 1

2

Question 2

The nurse prepares a care plan for a newly admitted older resident. What should be done with the plan at this time?
1) Notify the physician so changes can be made.
2) File it in a drawer since it will not be used for ongoing care.
3) Reevaluate and update the plan based on the patient's needs.
4) Inform the family that the plan is complete for the patient's stay.

Answer 2

3

Question 3

The nurse reviews the medical diagnoses for an older patient. In which way should the nursing diagnoses identified for this patient differ from the medical diagnoses?
1) It focuses on prescribed treatments.
2) It identifies specific signs and symptoms.
3) It identifies a specific disease process affecting a body system.
4) It describes the impact a specific disease has on a patient's activities.

Answer 3

4

Question 4

The nurse is completing an admission assessment. What information should be included? Select all that apply.
1) Nursing history
2) Physical examination
3) Interview with the resident
4) Review of laboratory values
5) Previous facility nurse's notes

Question 5

An older patient has the nursing diagnosis of impaired skin integrity related to a stasis ulcer on the left ankle. Which would be a goal for this nursing diagnosis?
1) The resident will not have any more leg ulcers.
2) The nurse will change the wound dressing b.i.d. until healed.
3) The nurse will chart any wound drainage and report it to the physician.
4) The stasis ulcer will have decreased redness and granulation tissue evident in 2 weeks.

Question 6

The nurse is asked to explain the nursing process. In which way should the nurse describe this process?
1) A step-by-step linear plan
2) A problem-solving process
3) A standardized plan of care for specific diseases or disorders
4) A plan of care designed by the physician according to the medical diagnosis

Question 7

The nurse reviews goals written for an older patient. Which aspect of a goal is missing from the statement "the resident will walk down the hall every day"?
1) Specificity
2) Timeliness
3) Attainability
4) Measurability

Question 8

The nurse is assessing a new resident. What should the nurse include when using the resident assessment instrument (RAI)? Select all that apply.
1) Minimum data set (MDS)
2) RAI utilization guidelines
3) Care area assessment (CAA)
4) Medication reconciliation form
5) Medicare and Medicaid conditions of participation

Question 9

An older resident is discharged to home. What should be done with this resident's plan of care?
1) Discard it.
2) Provide a copy to the family.
3) Keep it with the medical record.
4) Send it to the resident's physician.

Question 10

The nurse provides a resident with medication to aid with constipation. What should be included when documenting this intervention?
1) Resident's response
2) Number of pills remaining
3) Number of residents needing the medication
4) Resident's location when the medication was given

Question 11

The nurse is planning care for an older resident with an elevated blood pressure. What should the nurse identify as a goal for this resident's care?
1) The resident's blood pressure will be normal.
2) The resident's blood pressure will not be elevated.
3) The resident's blood pressure will be monitored three times a day for 1 week.
4) The resident's blood pressure will be less than 160/90 mm Hg in 1 week.