Chapter 05: Introduction to the Nursing Process

A nurse admits a patient to the cardiac care unit following the placement of a cardiac stent. Which step of the nursing process does the nurse do first? a. Planning b. Assessment c. Evaluation d. Implementation

ANS: B The nurse first assesses the patient. Collecting an extensive health history and completing a thorough head-to-toe physical assessment are typically required when a patient is admitted to a hospital or seeking health care from a primary care provider for the first time. This information provides a baseline for future reference. Shorter, focused assessments are conducted by the nurse routinely throughout hospitalization or during repeated clinic visits to assess a patient's change of status.

Which statement is an appropriately written short-term goal? a. Patient will walk to the bathroom independently without falling within 2 days after surgery. b. Nurse will watch patient demonstrate proper insulin injection technique each morning. c. Patient's spouse will express satisfaction with patient's progress before discharge. d. Patient's incision will be well approximated each time it is assessed by the nurse.

Answer: a Goals are to be patient-focused, realistic, and measurable. Only the first goal meets these three criteria.

What should be the primary focus for nursing interventions? a. Patient needs b. Nurse concerns c. Physician priorities d. Patient's family requests

Answer: a Patient needs are always the primary focus of nursing interventions. Nursing concerns, physician priorities, and family requests can provide additional guidance in the development of a patient-centered plan of care.

A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? a. Identify reasons the patient is unable to sleep. b. Request medication to help the patient sleep. c. Tell the patient that sleep will come with relaxation. d. Notify the physician that the patient is restless and anxious.

Answer: a When a patient shares a concern, the first action by the nurse is to assess potential reasons for the patient's problem. Depending on the underlying reason for the patient's inability to sleep, the nurse may then want to administer prescribed sleep medication, teach the patient some relaxation techniques, or discuss patient behaviors with the primary care provider.

What is the primary purpose of the nursing diagnosis? a. Resolving patient confusion b. Communicating patient needs c. Meeting accreditation requirements d. Articulating the nursing scope of practice

Answer: b Each nursing diagnosis label identifies either a patient problem or need, which is its purpose. Resolving patient confusion, meeting accreditation requirements, and articulating the nurse's scope of practice are not related to the purpose of the nursing diagnostic process.

Which nursing action is critical before delegating interventions to another member of the health care team? a. Locate all members of the health care team. b. Notify the physician of potential complications. c. Know the scope of practice for the other team member. d. Call a meeting of the health care team to determine the needs of the patient.

Answer: c Knowing the scope of practice of the other team member is critical to understanding what is appropriate and safe to delegate to that person. It is unnecessary to locate or meet with all members of the health care team prior to delegation. Physicians are already aware of potential complications related to patient care.

On what premise is a nursing diagnosis identified for a patient? a. First impressions b. Nursing intuition c. Clustered data d. Medical diagnoses

Answer: c Nursing diagnoses emerge from groupings of clustered data collected during the assessment phase of the nursing process. The nurse documents the patient's medical diagnosis as one piece of data, which may be clustered with others to support a nursing diagnosis. Data collected from a nurse's intuition and first impressions may also be listed in the patient's assessment findings as long as they are objectively recorded without prejudice and are not judgmental in nature.

Which body is responsible for defining and disseminating information on nursing diagnoses? a. North American Nursing Diagnosis Association International b. International and American Nurses Association c. Individual State Boards of Nursing d. The Joint Commission

ANS: A Nursing diagnoses are established and revised biannually by NANDA International, Inc. (NANDA-I), a professional nursing organization that provides standardized language to identify patient problems and plan customized care.

Which long-term goal is written correctly? a. Patient will remain afebrile throughout hospitalization. b. Patient will return to professional sports activities within 6 months. c. Nurse will prevent bone infection through antibiotic therapy for 3 weeks. d. Patient will demonstrate accurate use of crutches without assistance before discharge from emergency room.

ANS: B "Patient will return to professional sports activities within 6 months" is a correctly written long-term goal. Goals that are achievable within an immediate time frame of less than approximately one week are short-term goals, whereas goals that will take more time to achieve—weeks to months—are long-term goals. All short- and long-term goals must be (1) patient focused, (2) realistic, and (3) measurable.

What should be the focus of all nursing interventions? a. Early hospital discharge for patients b. Providing patient-centered care c. Reduction of health care spending d. Delegating appropriate nursing care

ANS: B All patients are required to have unique, patient-centered plans of care designed to meet their specific needs.

Which statement illustrates the most measurable outcome indicator? a. Demonstrates dressing change b. Shares innermost thoughts c. Understands instructions d. Shows personal remorse

ANS: A "Demonstrates dressing change" is a measurable outcome indicator. Outcome identification, added by the ANA in 1991 as a specific aspect of the nursing process, involves listing behaviors or observable items that indicate attainment of a goal. The other options are not measurable as written.

Which action should the nurse take 30 minutes after administering oral pain medication to a patient? a. Evaluate the effectiveness of the administered pain medication. b. Teach progressive relaxation strategies to relieve muscle tension. c. Assess the patient's coping skills to reduce expressed anxiety. d. Encourage the patient to read or watch TV to provide pain distraction.

ANS: A Evaluation focuses on the patient and the patient's response to nursing interventions and goal or outcome attainment. During the evaluation step of the nursing process, nurses use critical thinking to determine whether a patient's short- and long-term goals were met and desired outcomes were achieved.

Which statement is a correctly written example of an actual nursing diagnosis? a. Impaired memory related to patient complaint of becoming confused with the time change b. Risk for injury related to stumbling when walking as evidenced by patient report of occasional difficulty playing basketball c. Activity intolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea on exertion and significant drop of oxygen saturation from 98% to 88% with activity d. Ineffective health maintenance as evidenced by inability to complete activities of daily living related to lack of familial support system

ANS: C Actual nursing diagnoses are written with three parts, whereas risk nursing diagnoses and health-promotion nursing diagnoses contain only two parts. Three-part nursing diagnosis statements include (1) the patient's identified need or problem (i.e., NANDA-I nursing diagnostic label), (2) the etiology or underlying cause (i.e., related to [r/t]), and (3) signs and symptoms (i.e., as evidenced by [AEB] or as manifested by [AMB]). Sleep Deprivation related to frequent sleep interruption as evidenced by patient complaint of diarrhea 10 times throughout the night and feeling fatigued is an example of a three-part nursing diagnosis statement.

The statement "ongoing collection of data" best describes which phase of the nursing process? a. Planning b. Evaluation c. Assessment d. Implementation

ANS: C Keeping the five steps of the nursing process in mind, a nurse conducts ongoing assessment (data collection) as a patient's condition changes and modifies the patient's plan of care on the basis of those findings.

A disoriented patient is admitted to the hospital accompanied by his spouse. From whom should the nurse collect subjective data on this patient? a. An experienced nurse on the unit b. The patient's medical record c. The patient's wife d. His physician

ANS: C Subjective data (i.e., symptoms) are spoken. Patients' feelings about a situation or comments about how they are feeling are examples of subjective data. Data shared by a source verbally are considered subjective. Subjective data may be difficult to validate because they cannot be independently and objectively measured. Subjective data are most often gathered during a patient interview or health history. Use of an interpreter may be necessary when the patient or family members speak a language unfamiliar to the nurse. Subjective data are typically documented in the patient's medical record as direct quotations; for example, "I didn't get much sleep last night" or "I've had diabetes since I was 10 years old."

What term best describes the nature of the nursing process? a. Static b. Linear c. Dynamic d. Predictable

ANS: C The nursing process is dynamic, changing over time in response to patients' individual needs. The dynamic, responsive nature of the nursing process allows it to be used effectively with patients in any setting and at every level of care, from the intensive care unit to outpatient wellness clinics.

Prior to identifying accurate nursing diagnoses, what action must be taken by the nurse? a. Reading the patient's history b. Setting realistic, measurable goals c. Comparing evidence-based practices d. Clustering related patient data

ANS: D In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. Reading the patient's history is part of assessment. Goal setting and considering evidence-based practice are part of planning.

A nurse admits a 5-year-old female to the postanesthesia unit following a tonsillectomy. The child is crying. What should be the nurse's first action? a. Tell the child that if she stops crying, her parents can be with her. b. Check to see what pain medication is ordered for the child. c. Notify the surgeon of the child's postoperative condition. d. Assess the child to determine why she is crying.

ANS: D Nurses assess the state of a patient's physical, psychological, emotional, environmental, cultural, and spiritual health to gain a better understanding of his or her overall condition.

What phrase best describes the essence of critical thinking? a. Understanding without conscious reasoning b. Providing care based on nursing experience c. Consulting with a primary care provider d. Seeking solutions to problems

ANS: D Seeking solutions to problems describes the essence of critical thinking. Paul (1988) describes critical thinking as a complex process during which individuals think about their thinking to provide clarity and increase precision and relevance in a specific situation while attempting to be fair and consistent.

What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. Consult the surgeon to see if the clinical pathway is being followed. b. Discontinue the plan of care, because the patient has met the established goal. c. Monitor patient urine output to evaluate the need for the current plan of care. d. Notify the patient that the goal has been attained and no further intervention is needed.

Answer: c The nurse should evaluate the need to continue or discontinue a plan of care if a patient has met a short-term goal. It is unnecessary to consult the surgeon unless there is a concern. Discontinuing the care plan may be premature, and the decision needs to be evaluated before taking action. The patient's intake and output will continue to be monitored throughout hospitalization, not just for 1 hour after surgery.

What is the purpose of the nursing process? a. Providing patient-centered care b. Identifying members of the health care team c. Organizing the ways nurses think about patient care d. Facilitating communication among members of the health care team

Answer: c The nursing process is the methodology used to "think like a nurse." Providing patient-centered care and enhancing communication among health team members is facilitated through the use of care plans. Collaborating with rather than identifying members of the health care team is part of many plans of care.

A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. Family history of diabetes b. Medications the patient is taking c. Operations the patient has had in the past d. Severity and duration of the nausea and vomiting

Answer: d In an emergent situation, the nurse initially focuses on the patient's chief complaint to determine its cause. Before initiating care, the nurse gathers information on the other topics.

An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient? a. Family member b. Physician c. Another nurse d. Patient

Answer: d The nurse collects primary data directly from patients who are alert and oriented. Family members and other members of the health care team may provide secondary data on patients.