Deck 5: Assessment, Nursing Diagnosis, and Planning

Question 1

A nursing diagnosis consists of:

A) the health care provider's medical diagnosis listed as the nursing diagnosis.
B) diagnostic labels formulated by the North American Nursing Diagnosis Association-International (NANDA-I).
C) the patient's explanation of his or her "chief complaint" or "current complaint."
D) the results of the nursing assessment without consideration of doctor's orders.

Answer 1

diagnostic labels formulated by the North American Nursing Diagnosis Association-International (NANDA-I).

Question 2

The nurse performing an admission interview on an older adult person should:

A) rush through the interview to avoid tiring the patient.
B) direct questions to the family rather than the patient.
C) allow more time for a response to questions.
D) prompt the patient to speed recall.

Answer 2

allow more time for a response to questions.

Question 3

The nursing diagnoses that has the highest priority is:

A) Mobility, impaired physical, related to muscular weakness as evidenced by the inability to walk without assistance.
B) Communication, impaired verbal, related to neuromuscular weakness as evidenced by facial weakness and inability to speak.
C) Imbalanced nutrition: less than body requirements, related to difficulty swallowing and inadequate food intake as evidenced by weight loss of 10 pounds.
D) Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating.

Answer 3

Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating.

Question 4

The North American Nursing Diagnosis Association-I (NANDA-I) list is revised and updated every:

A) year.
B) 2 years.
C) 3 years.
D) 5 years.

Question 5

The nurse takes into consideration that the difference between a sign and a symptom is that a sign is:

A) subjective data.
B) unreliable because it depends on translation.
C) can be verified by examination.
D) something a patient reports that is verified by a relative.

Question 6

An example of a structured format for gathering data that aids in forming a database is:

A) North American Nursing Diagnosis Association-International (NANDA-I).
B) Maslow's hierarchy.
C) QSENl
D) Gordon's 11 Health Patterns.

Question 7

In an acute care facility, a nursing care plan is usually reviewed and updated:

A) every shift.
B) every 24 hours.
C) once every 3 days.
D) on admission and discharge.

Question 8

A patient with visual impairment is identified as at-risk for falls related to blindness. An appropriate intervention would be:

A) assist the patient with feeding herself at the end of the meal.
B) arrange furnishings in room to provide clear pathways and orient the patient to these.
C) take the patient's blood pressure before she gets up in the morning.
D) report any falls immediately to the charge nurse and the doctor.

Question 9

A nursing care plan consists of:

A) nursing orders for individualized interventions to assist the patient to meet expected outcomes.
B) orders for diagnostic and therapeutic procedures such as laboratory tests or radiographs.
C) the health care provider's history and physical examination, as well as medical diagnoses.
D) laboratory and radiograph reports, pathology reports, and the medication record.

Question 10

If a patient has several nursing diagnoses, the nurse will first:

A) consult with the doctor regarding which diagnosis is most important.
B) devise nursing interventions for the most quickly solved problems.
C) prioritize the nursing problems according to Maslow's hierarchy of needs.
D) review the patient's medical prescriptions and other drugs being taken.

Question 11

The nurse clarifies that nursing orders are also called:

A) goals.
B) qualifiers.
C) interventions.
D) measurement criteria.

Question 12

During the assessment phase of the nursing process, the nurse:

A) develops a care plan to meet the patient's nursing needs.
B) begins to formulate plans for providing nursing intervention.
C) establishes a nursing diagnosis for the nursing care plan.
D) gathers, organizes, and documents data in a logical database.

Question 13

The nurse designs the goals for patients in long-term facilities to be:

A) conditional.
B) open ended.
C) based on behavioral norms.
D) long term.

Question 14

An older adult patient with a medical diagnosis of chronic lung disease has developed pneumonia. She is coughing frequently and expectorating thick, sticky secretions. She is very short of breath, even with oxygen running, and she is exhausted and says she "can't breathe." Based on this information, an appropriately worded nursing diagnosis for this patient is:

A) Airway clearance, ineffective, related to lung secretions as evidenced by cough and shortness of breath.
B) Pneumonia, cough, and shortness of breath related to chronic lung disease.
C) Difficulty breathing not relieved by oxygen and evidenced by shortness of breath.
D) Cough and shortness of breath caused by pneumonia, chronic lung disease, advanced age, and exhaustion.

Question 15

A patient has a nursing diagnosis of imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months. An appropriate short-term goal for this patient is to:

A) eat 50% of six small meals every day by the end of 1 week.
B) demonstrate progressive weight gain over 6 months.
C) eat all of the meals prepared during admission.
D) verbalize understanding of caloric needs and intention to eat.

Question 16

A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is:

A) Airway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung.
B) Airway clearance, ineffective, related to right lower lobe pneumonia as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung.
C) Right lower lobe pneumonia, related to airway clearance, ineffective, as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung.
D) Expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung related to right lower lobe pneumonia as evidenced by airway clearance.

Question 17

Standardized Nursing Care Plans can:

A) be documented without alteration.
B) have items altered or deleted.
C) become part of the record without documentation.
D) help the family understand the concept of Nursing Care Plans.

Question 18

When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _______ data.

A) objective
B) medical
C) subjective
D) adjunct

Question 19

The major goal of the admission interview (usually performed by the RN) is to:

A) establish rapport.
B) help the patient understands the objectives of care.
C) identify the patient's major complaints.
D) initiate nursing care plan forms.

Question 20

After the admission assessment is completed, on subsequent shifts or days, the nurse:

A) does not assess the patient again unless the condition changes.
B) refers only to the admission assessment during the hospitalization.
C) performs a complete physical examination every day.
D) assesses the patient briefly in the first hour of the shift.

Question 21

The nurse should make a point when closing the initial interview to: (Select all that apply.)

A) develop rapport.
B) summarize the problems discussed.
C) thank the patient for his or her time.
D) discuss the nursing goals associated with nursing diagnoses.
E) give a copy of the nursing care plan to the patient.

Question 22

Reginald is a nurse caring for a 56-year-old man who is admitted with an acute MI. As he completes the initial assessment, he knows that concerning the practice of nursing, the purpose of the assessment on admission is to:

A) gather data so that the patient's response to the treatment can be evaluated.
B) gather data for the health care provider, to make decisions based on the condition of the patient.
C) establish rapport with the patient so that he/she can feel safe and secure in the acute health care setting.
D) begin the care plan and set the patient on the road to recovery.

Question 23

A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurological impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.)

A) Assist with range of motion exercises every 4 hours and as needed.
B) Instruct patient to call for assistance when needing to get out of bed.
C) Apply wrist and ankle restraints to promote safety and prevent falls.
D) Teach about exercises that will strengthen muscles while lying in bed.
E) Ambulate with physical therapy assistance at least three times a day.

Question 24

The purpose of the Nursing Outcomes Classification (NOC) is to: (Select all that apply.)

A) validate classification by field test.
B) identify labels.
C) provide language labels for desired outcomes.
D) generate a readymade nursing care plan for a patient.
E) identify patient outcomes and indicators.

Question 25

Appropriate nursing roles in the initial assessment would include: (Select all that apply.)

A) LPN obtains the vital signs of a new patient.
B) RN performs a complete physical assessment.
C) LPN organizes data into a database.
D) RN reviews the patient's medical record for past medical/surgical history.
E) LVN contributes ongoing assessments.

Question 26

Theresa is a nurse caring for a 14-year-old girl who is admitted with an asthma attack. When she writes the nursing diagnosis statement she includes?

A) Two statements; the problem and the signs and/or the symptoms.
B) The medical diagnosis.
C) Her clinical judgment regarding the patient's response to the problem.
D) Uses the NANDA-I as the stem and the medical diagnosis as the conclusion.

Question 27

Aside from the information obtained from the patient (primary source) in the admission interview, the nurse will also access: (Select all that apply.)

A) the patient's family.
B) a reliable and up-to-date reference book.
C) the admission note.
D) the health care provider's history and physical.
E) an observation of the patient for nonverbal clues.

Question 28

A nursing diagnosis identifies: (Select all that apply.)

A) patient's response to illness.
B) related signs and symptoms.
C) underlying medical diagnosis.
D) causative factors.
E) potential risk for health problems.

Question 29

The nurse understands that an expected outcome should be: (Select all that apply.)

A) realistic.
B) approved by the health care provider.
C) attainable.
D) within a defined time.
E) included after patient collaboration.

Question 30

The statements that are correctly stated as expected outcomes are: (Select all that apply.)

A) patient will be able to void in the bathroom independently.
B) patient will be able to ambulate using a walker independently within 3 days.
C) the nurse will assist the patient to the bathroom three times a day.
D) patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours.
E) the family will bring food from home to improve patient appetite.

Question 31

Conclusions that have been made based on observed data are __________.

Question 32

The seven domains of the Nursing Interventions Classification (NIC) taxonomy include: (Select all that apply.)

A) community.
B) health system.
C) socioeconomic level.
D) safety.
E) behavioral.