MODULE 10 CHAPTERS 11-16 MULTIPLE CHOICE

. Which of the following characteristics of the nursing process could be defined as a great deal of overlapping interaction among the five steps, with each step being fluid and flowing into the next step? a. Interpersonal b. Dynamic c. Systematic d. Universally applicable

b. Dynamic

Which of the following actions should the nurse take when patient data indicate that the stated goals have not been achieved? a. Collect more data for the database. b. Review each preceding step of the nursing process. c. Implement a standardized plan of care. d. Change the nursing orders.

b. Review each preceding step of the nursing process.

During which of the following phases of the nurse-patient interview does the nurse gather all the information needed to form the subjec- tive database? a. Preparatory phase b. Introduction c. Working phase d. Termination

c. Working phase

2. Which of the following groups legitimized the steps of the nursing process in 1973 by devel- oping standards of practice to guide nursing practice? a. American Nurses Association Congress for Nursing Practice b. Joint Commission on Accreditation of Healthcare Organizations c. National League of Nursing d. American Association of Critical Care Nursing

a. American Nurses Association Congress for Nursing Practice

Which of the following actions is the most important act of evaluation performed by the nurse? a. Evaluating the patient's goal/outcome achievement b. Evaluating the plan of care c. Evaluating the competence of nurse practitioners d. Evaluating the types of healthcare services available to the patient

a. Evaluating the patient's goal/outcome achievement

Which of the following is an actual or potential health problem that can be prevented or resolved by an independent nursing intervention? a. Nursing diagnoses b. Nursing assessments c. Medical diagnoses d. Collaborative problems

a. Nursing diagnoses

Which of the following is a correctly written goal for a patient who is scheduled to ambulate following hip surgery? a. Over the next 24-hour period, the patient will walk the length of the hallway assisted by the nurse. b. The nurse will help the patient ambulate the length of the hallway once a day. c. Offer to help the patient walk the length of the hallway each day. d. Patient will become mobile within a 24-hour period.

a. Over the next 24-hour period, the patient will walk the length of the hallway assisted by the nurse.

Which of the following sources of patient data is usually the primary and best source? a. Patient b. Support people c. Patient records d. Reports of diagnostic studies

a. Patient

Which of the following patient goals would be considered a psychomotor goal? a. By 8/18/12, patient will value his health sufficiently to quit smoking. b. By 8/18/12, patient will have full motion in left arm. c. By 8/18/12, patient will list three foods that are low in salt. d. By 8/18/12, patient will learn three exercises designed to strengthen leg muscles.

b. By 8/18/12, patient will have full motion in left arm.

. Mr. Martin is an energetic 80-year-old, admit- ted to the hospital with complaints of difficulty urinating, bloody urine, and burning on urination. In assessing Mr. Martin, which of the following is a priority? a. Assessing only the urinary system b. Focusing on altered patterns of elimination common in the elderly c. Obtaining a detailed assessment of the patient's sexual history d. Conducting a thorough systems review to validate data on the patient's record

b. Focusing on altered patterns of elimination common in the elderly

. Your patient, who presented with high blood pressure, is put on a low-salt diet and instructed to quit smoking. You find him in the cafeteria eating a cheeseburger and french fries. He also tells you there is no way he can quit smoking. What is your first objective when implementing care for this patient? a. Explain to the patient the effects of a high-salt diet and smoking on blood pressure. b. Identify why the patient is not following the therapy. c. Collaborate with other healthcare professionals about the patient's treatment. d. Change the nursing care plan.

b. Identify why the patient is not following the therapy.

The etiology of the nursing diagnosis contains which of the following factors? a. Identification of the unhealthy response preventing desired change b. Identification of factors causing undesirable response and preventing desired change c. Suggestion of patient goals to promote desired change d. Identification of patient strengths

b. Identification of factors causing undesirable response and preventing desired change

Which of the following statements concerning nursing interventions is accurate? a. Nursing interventions are a separate entity from the original goal/outcome. b. Nursing interventions are dated when written and when the plan of care is reviewed. c. Nursing interventions are signed by the attending physician. d. Nursing interventions do not describe the nursing action to be performed

b. Nursing interventions are dated when written and when the plan of care is reviewed.

Which of the following phrases best describes the unique focus of nursing implementation? a. The selected aspects of the patient's treatment regimen b. The response of the patient to the plan of care in general c. The response of the patient to the illness d. The patient's ability to work with support people to promote wellness

b. The response of the patient to the plan of care in general

Mr. Rose, an overweight, highly stressed 50-year-old executive, is being discharged from the hospital after undergoing coronary bypass surgery. Which of the following demon- strates an affective goal for this patient? a. By 6/30/12, the patient will list three benefits of daily exercise. b. By 6/30/12, the patient will correctly demonstrate breathing techniques to reduce stress. c. By 6/30/12, the patient will value his health sufficiently to reduce the cholesterol in his diet. d. By 6/30/12, the patient will be able to plan healthy weekly menus.

c. By 6/30/12, the patient will value his health sufficiently to reduce the cholesterol in his diet.

Which of the following terms denotes a nurse's authority to initiate actions that normally require the order or supervision of a physician? a. Protocols b. Nursing interventions c. Collaborative orders d. Standing orders

c. Collaborative orders

Which of the following interpersonal skills is displayed by a nurse who is attentive and responsive to the healthcare needs of individ- ual patients and ensures the continuity of care when leaving the patient? a. Establishing caring relationships b. Enjoying the rewards of mutual interchange c. Developing accountability d. Developing ethical/legal skills

c. Developing accountability

Which of the following nursing actions is considered an independent (nurse-initiated) action? a. Executing physician orders for a catheter b. Meeting with other healthcare professionals to discuss a patient c. Helping to allay a patient's fears about surgery d. Administering medication to a patient

c. Helping to allay a patient's fears about surgery

Which of the following nurse-patient positioning facilitates an easy exchange of information? a. If the patient is in bed, the nurse stands at the foot of the bed. b. If both the nurse and patient are seated, their chairs are at right angles to each other, 1 foot apart. c. If the patient is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. d. If the patient is in bed, the nurse stands at the side of the bed.

c. If the patient is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

As the nurse bathes a patient, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone.Which of the following statements best explains why such continuing data collection is so important? a. It is difficult to collect complete data in the initial assessment. b. It is the most efficient use of the nurse's time. c. It enables the nurse to revise the care plan appropriately. d. It meets current standards of care.

c. It enables the nurse to revise the care plan appropriately.

Mr. Conner is a 48-year-old patient with a new colostomy. Which of the following patient goals for Mr. Conner is written correctly? a. Explain to Mr. Conner the proper care of the stoma by 3/29/12. b. Mr. Conner will know how to care for his stoma by 3/29/12. c. Mr. Conner will demonstrate proper care of stoma by 3/29/12. d. Mr. Conner will be able to care for stoma and cope with psychological loss by 3/29/12.

c. Mr. Conner will demonstrate proper care of stoma by 3/29/12.

4. Which of the following statements accurately depicts a step in the critical thinking process? a. The first step when thinking critically is to gather as much data related to the question as possible. b. Nurses who think critically allow emotions to direct their thinking. c. Nurses who use the critical thinking process ultimately must identify alternative decisions and reach a conclusion. d. The critical thinking process is based on intuition and excludes the use of outside resources.

c. Nurses who use the critical thinking process ultimately must identify alternative decisions and reach a conclusion.

Which of the following statements regarding nursing diagnoses is accurate? a. Nursing diagnoses remain the same for as long as the disease is present. b. Nursing diagnoses are written to identify diseases. c. Nursing diagnoses are written to describe patient problems that nurses can treat. d. Nursing diagnoses focus on identifying healthy responses to health and illness.

c. Nursing diagnoses are written to describe patient problems that nurses can treat.

Mrs. Smith is admitted to the hospital with complaints of left-sided weakness and difficulty speaking. Which of the following assessments contains the data that best represent a nursing assessment? a. Neurologic examination reveals partial paralysis and aphasic speech. b. Brain scan shows evidence of a clot in the middle cerebral artery. c. Patient is unable to communicate basic needs and cannot perform hygiene measures with left hand. d. Left-sided weakness and speech deficit indi- cate probable stroke.

c. Patient is unable to communicate basic needs and cannot perform hygiene measures with left hand

According to Maslow's hierarchy of human needs, which of the following examples would be the highest priority for a patient? a. Self-actualization needs b. Love and belonging needs c. Physiologic needs d. Safety needs

c. Physiologic needs

Which of the following nursing diagnoses would be written when the nurse suspects that a health problem exists but needs to gather more data to confirm the diagnosis? a. Actual b. Potential c. Possible d. Apparent

c. Possible

The nurse collects data in the evaluation step to determine which of the following? a. Patient health problems b. Assessment of the patient's underlying health problems c. Solution of health problems through goal achievement d. The effect of medical diagnosis

c. Solution of health problems through goal achievement

Which of the following statements concerning the nursing process is accurate? a. The nursing process is nurse oriented. b. The steps of the nursing process are separate entities. c. The nursing process is nursing practice in action. d. The nursing process comprises four steps to promote patient well-being.

c. The nursing process is nursing practice in action.

Which of the following nursing concerns is clearly the responsibility of the nurse? a. Monitoring for changes in health status b. Promoting safety and preventing harm; detecting and controlling risks c. Tailoring treatment and medication regimens for each individual d. All of the above

d. All of the above

Which of the following traits help nurses develop the attitudes and dispositions to think critically? a. Thinking independently b. Being intellectually humble c. Being curious and persevering d. All of the above

d. All of the above

For a patient with self-care deficit, the long- term goal is that the patient will be able to dress himself by the end of the 6-week therapy. For best results, the nurse should evaluate the patient's progress toward this goal at which of the following times? a. When the patient is discharged b. At the end of the 6-week therapy c. Only when the patient shows some progress d. As soon as possible

d. As soon as possible

During the nursing examination, Mrs. Jones becomes very tired, but there are still questions the nurse practitioner would like to address in order to have data for planning care. Which of the following actions would be most appropri- ate in this situation? a. Ask Mrs. Jones to wake up and try to answer your questions. b. Ask Mrs. Jones's husband to come in and answer your questions. c. Wait until the next day to obtain the answers to your questions. d. Ask Mrs. Jones if she objects to your interviewing her husband to obtain the needed data.

d. Ask Mrs. Jones if she objects to your interviewing her husband to obtain the needed data.

. Mrs. Anderson, age 50, is admitted to your unit with the diagnosis of scleroderma. You are unfamiliar with this condition. Which of the following would be your best source of information? a. Consult with the patient. b. Consult with the patient's doctor. c. Read the patient's chart. d. Consult nursing and medical literature

d. Consult nursing and medical literature

Which of the following actions would be an appropriate nursing action when evaluating a patient's responses to a plan of care? a. Reinforce the plan of care when each expected outcome is achieved. b. Terminate the plan if there are difficulties achieving the goals/outcomes. c. Terminate the plan of care upon patient discharge. d. Continue the plan of care if more time is needed to achieve the goals/outcomes.

d. Continue the plan of care if more time is needed to achieve the goals/outcomes.

Which of the following would be an appropri- ate nursing diagnosis for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment? a. High Risk for Injury related to abusive parents b. High Risk for Injury related to impaired home management c. Child Abuse related to unsafe home environment d. High Risk for Injury related to unsafe home environment

d. High Risk for Injury related to unsafe home environment

In which of the following cases is the nursing process applicable? a. When nurses work with patients who are able to participate in their care b. When families are clearly supportive and wish to participate in care c. When patients are totally dependent on the nurse for care d. In all the nursing situations listed above

d. In all the nursing situations listed above

Data that can be observed by one person and verified by another person observing the same patient are known as: a. Subjective data b. Covert data c. Symptomatic data d. Objective data

d. Objective data

The quality assurance model of the ANA identifies three essential components of quality care. Which one of these components does the nurse use when determining whether a patient has met the goals stated on the care plan? a. Structure b. Process c. Retrospect d. Outcome

d. Outcome

Which of the following statements concerning quality improvement is accurate? a. Quality improvement is externally driven. b. Quality improvement follows organizational structure rather than patient care. c. Quality improvement focuses on individuals rather than processes. d. Quality improvement has no endpoints.

d. Quality improvement has no endpoints.

Which of the following actions would be performed during the planning step of the nursing process? a. Interpreting and analyzing patient data b. Establishing the database c. Identifying factors contributing to patient's success or failure d. Selecting nursing measures

d. Selecting nursing measures