Nursing Process

Which human responses identified by the nurse are examples of objective data? Select all that apply. 1. Irregular radial pulse of 50 beats per minute 2. Wheezing on expiration 3. Temperature of 99F 4. Shortness of breath 5. Dizziness

1, 2, 3

A nurse is interviewing a patient at the change of shift. Which patient statements reflect subjective data? Select all that apply. 1. "When I lift my head up off the bed, I feel like vomiting." 2. "I just went in the urinal, and it needs to be emptied." 3. "My pain feels like a 5 on a scale of 0 to 5." 4. "The physician said I can go home today." 5. "I ate only 50% of my breakfast."

1, 3

The nurse assess a patient and collects a variety of data. Identify the human responses that are subjective data. Select all that apply. 1. Nausea 2. Jaundice 3. Dizziness 4. Diaphoresis 5. Hypotension

1, 3

Which patient statements provide subjective data? Select all the apply. 1. "I'm not sure that I am going to be able to manage at home by myself." 2. "I can call a home-care agency if I feel I need help at home." 3. "What should I do if I have uncontrollable pain at home?" 4. "Will a home health aide help me with my care at home?" 5. "I'm afraid because I live alone and am on my own."

1, 5

Place the following statements that reflect the analysis step of the nursing process in the order in which they should be implemented. 1. Cluster data 2. Identify conclusions 3. Interpret clustered data 4. Communicate conclusion to other health team members 5. Identify when additional data are needed to further validate clustered data

1, 5, 3, 2, 4

Which most directly influences the planning step of the nursing process? 1. Related factors 2. Diagnostic label 3. Secondary factors 4. Medical diagnosis

1. Related factors (i.e., "contributing to" factors, etiology) contribute to the problem statement of the nursing diagnosis and directly impact the planning step of the nursing process. Nursing interventions are selected to minimize or relieve the effects of the related factors. If nursing interventions are appropriate and effective, the human response identified in the problem statement part of the nursing process will resolve.

Which information supports the appropriateness of a nursing diagnosis? 1. Defining characteristics 2. Planned interventions 3. Diagnostic statement 4. Related risk factors

1. The defining characteristics are the major and minor cues that form a cluster that support or validate the presence of a nursing diagnosis. At least one major defining characteristic must be present for a nursing diagnosis to be considered appropriate for the patient.

Which statement is related to the concept that is central to the nursing process? 1. It is dynamic rather than static. 2. It focuses on the role of the nurse. 3. It moves from the simple to the complex. 4. It is based on the patient's medical problem.

1. The nursing process is a dynamic five-step problem-solving process (assessment, analysis, planning, implementation, and evaluation) designed to diagnose and treat human responses to health problems.

A nurse evaluates a patient's response to a nursing intervention. To which aspect of the nursing process is this evaluation most directly related? 1. Goal 2. Problem 3. Etiology 4. Implementation

1. To evaluate the effectiveness of a nursing action, the nurse must compare the actual patient outcome with the expected patient outcome. The expected outcomes are the measurable data that reflect goal achievement, and the actual outcomes are what really happened.

Which nursing action reflects an activity associated with the analysis step of the nursing process? Select all that apply. 1. Formulating a plan of care. 2. Identifying the patient's potential risks. 3. Categorizing data into meaningful relationships. 4. Designing way to minimize a patient's stressors. 5. Making decisions about the effectiveness of patient care.

2, 3 2. Potential risk factors are identified during the analysis step of the nursing process. Risk diagnoses are designed to address situations in which patients have a particular vulnerability to health problems. 3. Determining which data are significant or insignificant and then categorizing the meaningful data into clusters of data that are related are parts of the analysis step of the nursing process.

A nurse assesses that a patient has slurred speech and a retained bolus of food in the mouth. The presence of which additional patient assessments should be clustered with this groups of signs and symptoms? Select all that apply. 1. Dyspnea 2. Coughing 3. Drooling 4. Gurgling 5. Plaque

2, 3, 4 The body continuously secretes saliva (approx 1L/day) that is usually swallowed. 2. Coughing: If a patient his having difficulty swallowing, they may aspirate saliva, which can cause coughing. 3. Drooling: When saliva accumulates and is not swallowed, it dribbles out of the mouth (drooling). Drooling in addition to the patient's other clinical manifestations indicates that the patient may have impaired swallowing. 4. Gurgling: When saliva accumulates and is not swallowed, it makes a bubbling or gurgling sounds in the posterior oropharynx as air is inhaled and exhaled.

The following statements reflect steps in the nursing process. Place the statements in order as the nurse advances through the steps of the nursing process, beginning with assessment and ending with evaluation. 1. "The patient is encouraged to attempt to defecate after meals." 2. "The patient reports not having had a bowel movement for 8 days." 3. "The patient has constipation related to limited mobility and inadequate fluid intake." 4. "The patient will have a bowel movement within 2 days that is of normal consistency." 5. "The patient's stool is still hard and dry 2 days after initiating an increase in fluids and activity."

2, 3, 4, 1, 5

A nurse identifies that the patient's report of decreased activity and intake of fluids may be the underlying cause of the patient's constipation. Which step of the nursing process does this reflect? 1. Assessment 2. Analysis 3. Planning 4. Implementation 5. Evaluation

2. Determining relationship of data and their significance are associated with the analysis phase of the nursing process.

During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are achieved? 1. Implementation 2. Evaluation 3. Diagnosis 4. Planning

2. Evaluation occurs when actual outcomes are compared with expected outcomes that reflect goal achievement. If the goal is achieved, the patient's needs are met.

Which should the nurse do during the evaluation step of the nursing process? 1. Set the time frames for goals. 2. Revise a plan of care. 3. Determine priorities. 4. Establish outcomes.

2. Revising a plan of care takes place in the evaluation step of the nursing process. If during the evaluation it is determined that the goal was not met, the reasons for failure have to identified, and the plan modified.

When considering the nursing process, the word "observe" is to "assess" as the word "explore" is to which of the following words? 1. Plan 2. Analyze 3. Evaluate 4. Implement

2. The definitions of the words "observe" and "assess" are similar. "Observe" means to view something scientifically, and "assess" means to collect information. The word "analyze" fits the analogy. Explore means to examine. Analysis means to investigate.

Which is the primary goal of the assessment phase of the nursing process? 1. Build trust 2. Collect data 3. Establish goals 4. Validate the medical diagnosis

2. The primary purpose of the assessment step of the nursing process is to collect data (information) from various sources using a variety of approaches.

Which word best describes the role of the nurse when using the nursing process to meet the needs of the patient holistically? 1. Teacher 2. Advocate 3. Surrogate 4. Counselor

2. When the nurse supports, protects, and defends a patient from a holistic perspective, the nurse functions as an advocate. Advocacy includes exploring, informing, mediating, and affirming in all areas to help a patient navigate the health-care system, maintain autonomy, and achieve the best possible health outcomes.

A nurse teaches a patient to use visualization to cope with chronic pain. Which step of the nursing process is associated with this nursing intervention? 1. Planning 2. Analysis 3. Evaluation 4. Implementation

4. This is an example of the implementation step of the nursing process. It is during the implementation step that planned nursing care is delivered.

A nurse collects information about a patient. Which should the nurse do next? 1. Plan nursing interventions 2. Write patient goals 3. Formulate nursing diagnoses 4. Determine significance of the data

4. After data are collected, they are clustered to determine their significance.

A nurse concludes that a patient's elevated temperature, pulse, and respirations are significant. Which step of the nursing process is being used when the nurse comes to this conclusion? 1. Implementation 2. Assessment 3. Evaluation 4. Analysis

4. During the analysis step of the nursing process, data are critically explored and interpreted, significance of data is determined, inferences are made and validated, cues and clusters of cues are compared with the defining characteristics of nursing diagnoses contributing factors are identified, and nursing diagnoses are identified and organized in order of priority.

A nurse is collecting subjective data associated with a patient's anxiety. Which assessment method should be used to collect this information? 1. Observing 2. Inspecting 3. Auscultation 4. Interviewing

4. Interviewing a patient is the most effective data collection method when collecting subjective data associated with a patient's anxiety. The patient is the primary source for subjective data about beliefs, values, feelings, perceptions, fears, and concerns.

When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of the patient?: 1. Reassess the patient 2. Examine the "related to" factors 3. Analyze the "secondary to" factors 4. Review the defining characteristics

4. The first thing the nurse should do to differentiate between two closely-associated nursing diagnoses is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.

When the nurse considers the nursing process, the word "identify" is to "recognize" as the word "do" is to which of the following words? 1. Plan 2. Evaluate 3. Diagnose 4. Implement

4. This is the correct analogy. The words "identify" and "recognize" have the same definition. The both mean the same as "that which is known." The words "do" and "implement" both have the same definition. They both mean "to carry out some action."

Which statement indicates that the nurse is using inductive reasoning? Select all that apply. 1. A patient is admitted with a diagnosis of dehydration and the nurse assesses the patient's skin for tenting. 2. A nurse observes a patient falling out of bed on the right hip and immediately assesses the patient for pain in the right hip. 3. A patient has an elevated white blood cell count and a fever. The nurse concludes that the patient may have an infection. 4. A patient is scheduled for surgery and is crying, trembling, and has a rapid pulse. The nurse makes the inference that the patient is anxious. 5. A nurse receives a call from the admission department that a patient with hypoglycemia is being admitted to the unit. The nurse plans to assess the patient for pale, cool, clammy skin and a low blood glucose level.

3, 4 These statements reflect the nurse using inductive reasoning. They move from the specific to the general. 3. A pattern of information (an elevated white blood cell count and elevated temperature) leads to a generalization (the patient may have an infection). 4. A pattern of information (crying, trembling, and a rapid pulse) leads to a generalization (the patient may be anxious).

A nurse is interviewing a patient. Which patient statements are examples of objective data? Select all that apply. 1. "I am hungry." 2. "I feel very warm." 3. "I ate half my lunch." 4. "I have a rash on my arm." 5. "I have the urge to urinate." 6. "I vomit every time I eat something."

3, 4, 6

A nurse is caring for a patient with a urinary elimination problem. Which are accurately-stated goals? Select all that apply. 1. "The patient will be taught how to use a bedpan while on bedrest." 2. "The patient will experience fewer incontinence episodes at night." 3. "The patient will transfer independently and safely to a toilet before discharge." 4. "The patient will be assisted to the commode every two hours and whenever necessary." 5. "The patient will experience one or less events of urinary incontinence daily within 6 weeks."

3, 5 Goals must be patient-centered, measurable, realistic, and include the time frame in which the expected goal is to be achieved. 3. The word "independently" indicates that no help is needed, and the word "safely" indicates that no injury will occur. The time frame is "before discharge." 5. The words "one or less event...daily" comprise a measurable statement, and the words "within 6 weeks" establish a time frame.

A pebble dropped into a pond causes ripples on the surface of the water. Which part of the nursing diagnosis is most directly related to this concept? 1. Defining characteristics 2. Outcome criteria 3. Etiology 4. Goal

3. The etiology (also known as related to or contributing factors) are the conditions, situations, or circumstances that cause the development of the human response identified in the problem statement of the nursing diagnosis. The etiology precipitates the human response just as pebble dropped in a pond causes ripples on the surface of water.

During which step of the nursing process does determining which actions will be employed to meet the needs of a patient occur? 1. Implementation 2. Assessment 3. Planning 4. Analysis

3. The identification of nursing actions designed to help a patient achieve a goal occurs during the planning step of the nursing process.

Which word is most closely associated with scientific principles? 1. Data 2. Problem 3. Rationale 4. Evaluation

3. The word "rationale" (justification based on reasoning) is closely associated with the term "scientific principles" (established rules of action). Scientific principles are based on rationales.

Which action reflects the assessment step of the nursing process? 1. Taking a patient's apical pulse rate every 2 hours after being admitted for an episode of chest pain 2. Scheduling a patient's fluid intake over 12 hours when the patient has a fluid restriction 3. Examining a patient for injury after a patient falls in the bathroom 4. Obtaining a patient's respiratory rate after a nebulizer treatment

3. This action reflects the assessment step of the nursing process. Assessment involves collecting data via observation, physical examination, and interviewing.

A nurse is caring for a patient with a fever. Which is a well-designed goal for this patient? 1. "The patient will have a lower temperature." 2. "The patient will be taught how to take an accurate temperature." 3. "The patient will maintain fluid intake adequate to prevent dehydration." 4. "The patient will be given aspirin every eight hours whenever necessary."

3. This is a well-written goal. Goals must be patient-centered, specific, measurable, and realistic and have a time frame in which the expected outcome is to be achieved. The words "adequate" and "dehydration" are based on generally-accepted criteria against which to measure the patient's actual outcome. The word "maintain" connotes continuously, which is a time frame.

Which is the primary reason why a nurse performs a physical assessment of a newly-admitted patient? 1. Identify if the patient is at risk for falls. 2. Ensure that the patient's skin is totally intact. 3. Identify important information about the patient. 4. Establish a therapeutic relationship with the patient.

3. This is the primary purpose of a nursing physical assessment. Data must be collected and then analyzed to determine significance and grouped in meaningful clusters before a nursing diagnosis or plan of care can be made.

Nurses use the nursing process to provide nursing care. These statements reflect nursing care being provided to a variety of patients. Place the statements in order as the nurse progresses through the steps of the nursing process, starting with assessment and ending with evaluation. 1. "Did you sleep last night after I gave you the sleeping medication?" 2. "The patient's clinical manifestations indicate dehydration." 3. "The patient will have a bowel movement in the morning." 4. "What brought you to the hospital today?" 5. "I am going to give you an enema."

4, 2, 3, 5, 1