Question 1

The nursing process is cyclic rather than linear. Because of the cyclic nature, as an individual patient's condition changes:

Accepted Answer

A)   The nurse's thought processes do not have to vary.
B)   Plans of care are easier to use and do not need modification.
C)   The accuracy and effectiveness of thought processes must be considered.
D)   Reflective thought is not necessary since issues tend to be repetitive. C

Question 2

The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a patient scheduled for back surgery. Which step of the nursing process is the nurse addressing?

Accepted Answer

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

Question 3

In which step of the nursing process does the nurse prioritize the nursing diagnoses and identify interventions to address the patient goals?

Accepted Answer

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

Question 4

Establishing short- and long-term goals to address nursing diagnoses involves: (Select all that apply.)

Accepted Answer

A)   discussion with the patient.
B)   exclusion of family with making patient decisions.
C)   collaboration with other members of health care team.
D)   making the health care provider as the central figure.
E)   coordination of care as collaborative care.

Question 5

The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The essential step that was added in 1991 is:

Accepted Answer

A)   assessment.
B)   diagnosis.
C)   outcome identification.
D)   evaluation.

Question 6

Which of the following statements would be considered objective data? (Select all that apply.)

Accepted Answer

A)   "I'm short of breath."
B)   "Blood pressure 90/68, apical pulse 102, skin pale and moist."
C)   "Lung sounds clear bilaterally, diminished in right lower lobe."
D)   "I feel weak all over when I exert myself."
E)   "My pain level is down to 2. It was 8."

Question 7

During a patient's bath, the nurse observes the patient having a tonic clonic seizure. The nurse immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of the nursing process?

Accepted Answer

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

Question 8

The nurse writes a short-term goal for a patient scheduled for surgery in the morning. The goal that contains all of the necessary elements is:

Accepted Answer

A)   The patient will walk to the bathroom within 48 hours after surgery.
B)   The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery.
C)   The patient will walk to the bathroom without experiencing shortness of breath.
D)   The patient will walk to the bathroom without experiencing shortness of breath after surgery.

Question 9

Which of the following is a correctly written nursing diagnosis appropriate for a patient's plan of care?

Accepted Answer

A)   Ineffective airway clearance related to excessive secretions as evidenced by diminished breath sounds.
B)   Imbalanced nutrition: less than body requirements.
C)   Impaired physical mobility related to contractures.
D)   Risk for suffocation related to smoking in bed as evidenced by absent breath sounds.

Question 10

The nurse is assisting a patient to bed when the patient says, "My chest hurts and my left arm feels numb. What's wrong with me?" What is the type and source of data obtained from the patient's complaint?

Accepted Answer

A)   Objective data from a primary source
B)   Objective data from a secondary source
C)   Subjective data from a primary source
D)   Subjective data from a secondary source

Question 11

A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process?

Accepted Answer

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

Question 12

The nurse is gathering data on a patient with acute bacterial pneumonia. This is an example of which step of the nursing process?

Accepted Answer

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

Question 13

The nurse is admitting a patient experiencing chest discomfort and shortness of breath. The patient also has a history of stroke. The nurse documents the nursing diagnosis "Risk for stroke related to history of stroke." The risk factor for this patient is:

Accepted Answer

A)   stroke.
B)   history of stroke.
C)   chest discomfort.
D)   shortness of breath.

Question 14

The charge nurse is discussing a patient's care plan during a team meeting. The team determines that the patient has not met the goal of "ambulating to the nurse's station twice a day" and decides to revise the plan. Which of the following characteristics of the nursing process most represents this decision?

Accepted Answer

A)   Organization
B)   Dynamics
C)   Adaptability
D)   Outcome orientation

Question 15

The nurse develops a list of nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, "I understand that I will lose most of my hair. Will it grow back?" Which of the following diagnoses will have the highest priority?

Accepted Answer

A)   Disturbed body image
B)   Nausea
C)   Risk for bleeding
D)   Imbalanced nutrition: less than body requirements

Question 16

The nursing process is the foundation of professional nursing practice. As such, the nursing process can be defined as:

Accepted Answer

A)   The framework that nurses used to provide care.
B)   A complex process during which nurses think about their thinking.
C)   The process that allows nurses to collect essential data.
D)   Thinking like a nurse in developing plans of care.

Question 17

The community health nurse is applying the nursing process to the care of patients with coronary artery disease. The nurse determines that most of the patients eat high-fat meals from the local fast-food restaurant and plans a nutrition workshop. The nurse is applying the nursing process characteristic of:

Accepted Answer

A)   organization.
B)   dynamics.
C)   adaptability.
D)   collaboration.

Question 18

All nursing interventions that are implemented for patients must be documented or charted. Proper documentation of interventions:

Accepted Answer

A)   facilitates communication with all members of the health care team.
B)   are only considered "legal" if documented in the paper chart.
C)   leads to errors of omission and repetition of care.
D)   does not directly measure goal achievement or outcomes.

Question 19

A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. The nurse asks the manager if there is a document written by the physician for this type of reaction. The nurse is referring to a:

Accepted Answer

A)   protocol.
B)   clinical pathway.
C)   standing order.
D)   care map.

Question 20

The nurse is attempting to develop nursing diagnoses for her patient. The nurse understands that nursing diagnoses: (Select all that apply.)

Accepted Answer

A)   identify actual or potential problems as well as responses to a problem.
B)   require naming patient problems using nursing diagnostic labels.
C)   utilize objective data since subjective data are often inaccurate.
D)   includes unvalidated data to determine an accurate and thorough diagnosis.
E)   are similar to medical diagnoses since they both are labels for diseases.

Exam 5: Introduction to the Nursing Process

The nursing process is cyclic rather than linear. Because of the cyclic nature, as an individual patient's condition changes:

The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a patient scheduled for back surgery. Which step of the nursing process is the nurse addressing?

In which step of the nursing process does the nurse prioritize the nursing diagnoses and identify interventions to address the patient goals?

Establishing short- and long-term goals to address nursing diagnoses involves: (Select all that apply.)

The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The essential step that was added in 1991 is:

Which of the following statements would be considered objective data? (Select all that apply.)

During a patient's bath, the nurse observes the patient having a tonic clonic seizure. The nurse immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of the nursing process?

The nurse writes a short-term goal for a patient scheduled for surgery in the morning. The goal that contains all of the necessary elements is:

Which of the following is a correctly written nursing diagnosis appropriate for a patient's plan of care?

The nurse is assisting a patient to bed when the patient says, "My chest hurts and my left arm feels numb. What's wrong with me?" What is the type and source of data obtained from the patient's complaint?

A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process?

The nurse is gathering data on a patient with acute bacterial pneumonia. This is an example of which step of the nursing process?

The nurse is admitting a patient experiencing chest discomfort and shortness of breath. The patient also has a history of stroke. The nurse documents the nursing diagnosis "Risk for stroke related to history of stroke." The risk factor for this patient is:

The nurse develops a list of nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, "I understand that I will lose most of my hair. Will it grow back?" Which of the following diagnoses will have the highest priority?

The nursing process is the foundation of professional nursing practice. As such, the nursing process can be defined as:

All nursing interventions that are implemented for patients must be documented or charted. Proper documentation of interventions:

A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. The nurse asks the manager if there is a document written by the physician for this type of reaction. The nurse is referring to a:

The nurse is attempting to develop nursing diagnoses for her patient. The nurse understands that nursing diagnoses: (Select all that apply.)