Nursing Process

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.

1. Although completing a nursing physical assessment includes an assessment of the risk for falls, it is only one component of the assessment. 2. Although completing a nursing physical admission assessment includes an assessment of the skin, it is only one component of the assessment. 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. 4. Although completing a nursing physical assessment helps to initiate the nursepatient relationship, it is not the primary purpose of completing a nursing admission assessment.

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

1. Although functioning as a teacher is an important role of the nurse, it is a limited role compared with another option. As a teacher, the nurse helps the patient gain new knowledge about health and health care to maintain or restore health. 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. 3. The word surrogate is not the word that best describes the role of the nurse providing holistic care. The nurse is placed in the surrogate role when a patient projects onto the nurse the image of another and then responds to the nurse with the feelings for the other person's image. 4. Although functioning as a counselor is an important role of the nurse, it is a limited role compared with another option. As counselor, the nurse helps the patient improve interpersonal relationships, recognize and deal with stressful psychosocial problems, and promote achievement of self-actualization.

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

1. Although trust may be established during the assessment phase of the nursing process, it is not the purpose of this step of the nursing process. The development of trust generally takes time. 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. 3. When a five-step nursing process is followed, formulating goals occurs during the planning, not assessment, step of the nursing process. 4. Validating the medical diagnosis is not within a nurse's legal scope of practice.

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

1. Defining characteristics do not contribute to the problem statement but support or indicate the presence of the nursing diagnosis. Defining characteristics are the major and minor signs and symptoms that support the presence of a nursing diagnosis. 2. Outcome criteria are not a part of the nursing diagnosis. Outcome criteria (goals) are part of the planning step of the nursing process. 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 a pebble dropped in a pond causes ripples on the surface of water. 4. Goals are not part of the nursing diagnosis. Goals are the expected outcomes or what is anticipated that the patient will achieve in response to nursing intervention.

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. Planning 4. Analysis

1. During the implementation step of the nursing process, outcomes are not determined, but rather planned nursing care is delivered. 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. 3. During the planning step of the nursing process, expected outcomes are determined, but their achievement is measured in another step of the nursing process. 4. During the analysis step of the nursing process, outcomes are not determined; rather, the nurse identifies human responses to actual or potential health problems.

When two nursing diagnoses appear closely related, which 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.

1. If a thorough assessment was completed initially, a reassessment should not be necessary. 2. To establish which of two nursing diagnoses is most appropriate is not dependent upon identifying the factors that contributed to (also known as related to or etiology of) the nursing diagnosis. These factors are identified after the problem statement is identified. 3. To establish which of two nursing diagnoses is more appropriate is not dependent upon analyzing the secondary to factors. Sec ondary to factors generally are medical conditions that precipitate the related to factors. The secondary to factors are identified after the related to factors of the problem are identified. 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.

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

1. Nursing care is planned after nursing diagnoses and goals are identified, not immediately after data are collected. 2. Goals are designed after a nursing diagnosis is identified, not after data are collected. 3. Once data are collected, the nurse must first organize and cluster the data to determine significance and make inferences. After all this is accomplished, then the nurse can formulate a nursing diagnosis. 4. After data are collected, they are clustered to determine their significance.

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 on 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 diagnosis will resolve. 2. The planning step of the nursing process includes setting a goal, identifying the outcomes that will reflect goal achievement, and planning nursing interventions. Although the wording of the goal is directly influenced by the diagnostic label (problem statement of the nursing diagnosis), the selection of nursing interventions is not. 3. Secondary factors generally have only a minor influence on the planning step of the nursing process. 4. The medical diagnosis does not influence the planning step of the nursing process. The nurse is concerned with human responses to actual or potential health problems, not the medical diagnosis.

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.

1. Setting time frames for goals to be achieved is part of the planning, not evaluation, step of the nursing process. 2. Revising a plan of care takes place in the evaluation step of the nursing process. If during evaluation it is determined that the goal was not met, the reasons for failure have to be identified and the plan modified. 3. Determining priorities is part of the planning, not evaluation, step of the nursing process. Priority setting is a decision-making process that ranks a patient's nursing needs and nursing interventions in order of importance. 4. Establishing outcomes is part of the planning, not evaluation, step of the nursing process.

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. 2. Planned interventions do not support the nursing diagnosis. They are the nursing actions designed to help resolve the "related to" or "contributing to" factors and achieve expected patient outcomes that reflect goal achievement. 3. The diagnostic statement cannot support the nursing diagnosis because it is the first part of the nursing diagnosis. A nursing diagnosis is made up of two parts, the diagnostic statement (also known as the problem statement) and the "related to" factors (also known as factors that contribute to the problem or the etiology). 4. Related risk factors cannot support the nursing diagnosis because they are the second part of the nursing diagnosis. A nursing diagnosis is made up of two parts, the diagnostic statement (also known as the problem statement) and the "related to" factors (also known as factors that contribute to the problem or the etiology).

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

1. The definitions of the words "observe" and "assess" are similar. Observe means to view something scientifically, and assess means to collect information. The word "plan" does not fit the analogy because the definitions of the words "plan" and "explore" are not similar. Explore means to examine. Plan means to design an intention. 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. 3. The definitions of the words "observe" and "assess" are similar. Observe means to view something scientifically, and assess means to collect information. The word "evaluation" does not fit the analogy because the definitions of explore and evaluate are not similar. Explore means to examine. Evaluation within the concept of the nursing process means to come to a conclusion about a patient's response to a nursing intervention. 4. The definitions of the words "observe" and "assess" are similar. Observe means to examine something scientifically, and assess means to collect information. The word "implement" does not fit the analogy because the definitions of explore and implement are not similar. Explore means to examine. Implement means to carry out an action.

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. 2. The nursing process focuses on the needs of the patient, not the role of the nurse. 3. Moving from the simple to the complex is a principle of teaching, not the nursing process. The nursing process is a complex interactive five-step problem-solving process designed to meet a patient's needs. It requires an understanding of systems and information-processing theory and the critical-thinking, problem-solving, decision-making, and diagnostic-reasoning processes. 4. The nursing process is concerned with a person's human responses to actual or potential health problems, not the patient's medical problem.

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

1. The word "data" (information) is not associated with the term "scientific principles" (established rules of action). 2. The word "problem" (difficulty) is not associated with the term "scientific principles" (established rules of action). 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. 4. The word "evaluation" (determining the value or worth of something) is not associated with the term "scientific principles" (established rules of action).

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

1. This action reflects the step of implementation. The nurse puts into action the plan to monitor the patient's vital signs after a cardiac event is suspected. 2. This action reflects the planning step of the nursing process. 3. This action reflects the assessment step of the nursing process. Assessment involves collecting data via observation, physical examination, and interviewing. 4. This action reflects the evaluation step of the nursing process. The nurse assesses the patient's respiratory rate and effort after a nebulizer treatment to determine if the treatment was effective in reducing airway resistance, thereby improving the patient's respiratory rate and reducing respiratory effort.

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

1. This does not occur during the implementation step of the nursing process. During the implementation step the nurse puts the plan of care into action. Nursing interventions include actions that are dependent (requiring a primary health-care provider's order), independent (autonomous actions within the nurse's scope of practice), and interdependent (interventions that require a primary health-care provider's order but that permit the nurse to use clinical judgment in their implementation). 2. This does not occur during the assessment step of the nursing process. During the assessment step the nurse uses various skills such as observation, interviewing, and physical examination to collect data from various sources. 3. The identification of nursing actions designed to help a patient achieve a goal occurs during the planning step of the nursing process. 4. This does not occur during the analysis step of the nursing process. The nurse identifies the patient's human responses to actual or potential health problems during the analysis step of the nursing process.

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."

1. This goal is inappropriate because the word "lower" is not specific, measurable, or objective. 2. This is not a goal. This is an action the nurse plans to implement to help a patient achieve a goal. 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.

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

1. This is not an example of the planning step of the nursing process. During the planning step the nurse identifies the nursing interventions that are most likely to be effective. 2. This is not an example of the analysis step of the nursing process. During the analysis step data are critically explored and interpreted, significance of data is determined, inferences are made and validated, signs and symptoms and clusters of signs and symptoms are compared with the defining characteristics of nursing diagnoses, contributing factors are identified, and nursing diagnoses are identified and organized in order of priority. 3. This is not an example of the evaluation step of the nursing process. Evaluation occurs when actual outcomes are compared with expected outcomes that reflect goal achievement. 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 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. 2. The problem is associated with the first half (problem statement) of the nursing diagnosis, not the evaluation step of the nursing process. 3. Etiology is a term used to identify the factors that relate to or contribute to the problem statement of the nursing diagnosis, not the evaluation step of the nursing process. 4. Implementation is a step separate from evaluation in the nursing process. Nursing care must be performed before it can be evaluated.