The Nursing Process

Assessment

100

To gather information about a patient’s home and work surroundings, the nurse will need to utilize which method of data collection? a. Carefully review lab results. b. Conduct the physical assessment before collecting subjective information. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview.

What is : C A thorough nursing history includes information about the patient’s home and work surroundings. Neither lab results nor the physical assessment will reveal much about the home and work surroundings. Collecting data is part of the working phase of the interview.

200

After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistant. With this in mind, what clinical decision should the nurse make? a. Administer scheduled medications assuming she would have been informed if the vital signs were abnormal. b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. c. Ask the nursing assistant to record the patient’s vital signs before administering medications. d. Omit the vital signs because the patient is presently in no distress.

What is: c. The nurse should ask the nursing assistant to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action.

300

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. This nurse should a. Notify the physician to recommend a psychological evaluation. b. Consider cultural differences during this assessment. c. Ask the patient to make eye contact to determine her affect. d. Continue with the interview and document that the patient is depressed.

What is: a. A patient’s feelings, perceptions, and reported symptoms. Subjective data include the patient’s feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition. Data sometimes reflect physiological changes, which you further explore through objective data collection. Describing the patient’s behavior, observations made, and measurements of a patient’s health status are all examples of objective data.

400

A patient expresses fear of going home and being alone. Her vital signs are stable and her incision is nearly completely healed. The nurse can infer from the subjective data that: a. The patient can now perform the dressing changes herself. b. The patient can begin retaking all her previous medications. c. The patient is apprehensive about discharge. d. Surgery was not successful

What is: c. The patient is apprehensive about discharge. Subjective data include expressions of fear of going home and being alone. These data indicate that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.

500

Which of the following are examples of subjective data? (Select all that apply.) a. Patient describing excitement about discharge b. Patient's wound appearance c. Patient’s expression of fear regarding upcoming surgery d. Patient pacing the floor while awaiting test results e. Patient’s temperature

What is a & c Subjective data include patient’s feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a patient’s health status. In this question, the appearance of the wound and the patient’s temperature are objective data. Pacing is an observable patient behavior and is also considered objective data.

Diagnoses

100

A new graduate nurse is not sure what the heart sound is that she is listening to on a patient. To avoid diagnostic error, what should the nurse do? a. Assign the nursing diagnosis of Decreased cardiac output. b. Ask the patient if he has a history of cardiac problems before assigning the diagnosis of Decisional conflict. c. Check the previous shift’s assessment and document what was noted on the last shift. d. Ask a more experienced nurse to listen also.

What is:D The potential diagnostic error here is an error in data collection. If a new nurse is not comfortable with his/her assessment technique, he or she should ask another nurse to validate the findings. Diagnosing before validating assessment findings leads to the potential for error. Assessment data are not sufficient to assign the diagnoses Decreased cardiac output and Decisional conflict. Every nurse needs to perform his or her own assessment. A patient’s status can change very rapidly. A nurse who copies the previous shift’s assessment is not practicing according to standards of practice and is violating the code of ethics.

200

The charge nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate to bathroom. The nurse needs to revise which part of the diagnostic statement? a. Nursing diagnosis b. Etiology c. Patient chief complaint d. Defining characteristic

What is b. Etiology The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the patient is unable to ambulate. The patient’s chief complaint is what the patient subjectively states is the problem. No subjective data are included in the diagnostic statement. The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility.

300

Which diagnosis below is NANDA-I approved? a. Sleep disorder b. Acute pain c. Sore throat d. High blood pressure

What is b. acute pain Acute pain is the only NANDA-I–approved diagnosis listed. Sleep disorder and high blood pressure (hypertension) are medical diagnoses, and sore throat is a subjective complaint.

400

The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is known as: a. Diagnostic reasoning. b. Defining characteristics. c. Assigning clinical criteria. d. Diagnostic labeling.

What is a. Diagnostic reasoning. Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Clinical criteria are objective signs or subjective symptoms. Diagnostic labeling is simply assigning the diagnosis.

500

A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences. Based on this information, an appropriate nursing diagnostic statement is Imbalanced nutrition: less than body requirements related to a. Religious preferences. b. Decreased oral intake. c. Weight loss. d. Race and ethnicity.

What is: B The cause or related to factor in this case is the patient’s lack of oral intake due to lack of appropriate food choices. The patient’s religious preferences, race, and ethnicity did not cause his weight loss. Ultimately, the lack of food choices and his decreased intake caused him to lose weight. Weight loss is a sign of imbalanced nutrition, not a cause. The weight loss would be noticed during the assessment and would lead to the nursing diagnosis, not in reverse order.

Planning

100

After completing a thorough database and analyzing the data to identify any problems, the nurse should proceed to what step of the nursing process? a. Assessment b. Planning c. Diagnoses d. Intervention

What is b. Planning In the five-step nursing process, the nurse should establish mutual goals with the patient and prioritize care in the planning phase, which follows the diagnosis phase. The assessment phase of the nursing process involves gathering data. The implementation phase involves carrying out appropriate nursing interventions. During the evaluation phase, the nurse assesses the effectiveness of interventions.

200

When planning patient care, a goal can be described as: a. A statement describing the patient’s accomplishments without a time restriction. b. A realistic statement predicting any negative responses to treatments. c. A broad statement describing a desired change in patient behavior. d. An identified long-term nursing diagnosis.

What is c. A broad statement describing a desired change in patient behavior. A goal is a broad statement that describes a desired change in a patient’s condition or behavior. A goal is mutually set with the patient and is time-limited, patient-centered, measurable, and realistic.

300

A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. The nurse should revise the plan of care first by a. Asking physical therapy to assist the patient because of the new injuries. b. Disregarding all previous diagnoses and establishing a new plan of care. c. Reassessing the patient. d. Reassessing the patient.

What is c. Reassessing the patient. The nurse needs to reassess the patient after any type of change in health status. The nursing process is dynamic and ongoing. Asking physical therapy to assist the patient is premature before reassessing the patient and awaiting physician orders. The nurse may not need to disregard all previous diagnoses. Some diagnoses may still apply, but the patient needs to be reassessed first. Setting new priorities is not recommended before assessment and establishing diagnoses.

400

When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by a. Ambulating in the hallway two times this shift. b. Turning side to back to side with assistance every 2 hours. c. Using the walker correctly to ambulate to the bathroom as needed. d. Using a sliding board correctly to transfer to the bedside commode as needed.

What is b. Turning side to back to side with assistance every 2 hours. The patient is ordered to be on bed rest; therefore turning the patient in bed is the only option that is appropriate. When determining goals, the nurse needs to ensure that the goal is individualized and realistic for the patient.

500

The following statements are on a patient’s nursing care plan. Which of the following statements is written as an outcome? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased mobility in 2 days. c. The patient will demonstrate increased tolerance to activity over the next month. d. The patient will understand needed dietary changes by discharge.

What is a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. An expected outcome is a specific and measurable change that is expected as a result of nursing care. The other three options in this question are goals. Demonstrating increased mobility in 2 days and understanding necessary dietary changes by discharge are short-term goals because they are expected to occur in less than a week. Demonstrating increased tolerance to activity over a month-long period is a long-term goal because it is expected to occur over a longer period of time.

Implementation

100

The step in the nursing process where the nurse provides nursing care interventions to patients?

What is Implementation

200

Before implementing any intervention, the nurse uses critical thinking to a. Determine whether an intervention is correct and appropriate for the given situation. b. Evaluate the effectiveness of interventions. c. Establish goals for a particular patient without the need for reassessment. d. Read over the steps and perform a procedure despite lack of clinical competency.

What is a. Determine whether an intervention is correct and appropriate for the given situation. Before implementing any intervention, the nurse uses critical thinking to determine whether an intervention is correct and appropriate for a clinical situation. The nurse cannot evaluate interventions until they are implemented. Patients need ongoing assessment because patient conditions can change very rapidly. The nurse needs to recognize the safety hazards of performing an intervention without clinical competency and seek assistance from another nurse.

300

Which of the following is a nursing intervention? a. The patient will ambulate in the hallway twice this shift using crutches correctly. b. Impaired physical mobility related to inability to bear weight on right leg c. Provide assistance while the patient walks in the hallway twice this shift with crutches. d. The patient is unable to bear weight on right lower extremity.

What is c. Provide assistance while the patient walks in the hallway twice this shift with crutches. Providing assistance to a patient who is ambulating is a nursing intervention. The statement, “The patient will ambulate in the hallway twice this shift using crutches correctly” is a patient goal. Impaired physical mobility is a nursing diagnosis. The statement that the patient is unable to bear weight and ambulate can be included with assessment data and is a defining characteristic for the diagnosis of Impaired physical mobility.

400

A newly admitted patient who is morbidly obese asks the nurse to assist her to the bathroom for the first time. What should the nurse do first? a. Ask for at least two other assistive personnel to come to the room. b. Medicate the patient to alleviate discomfort while ambulating. c. Offer the patient a walker. d. Review the patient’s activity orders.

What is d. Review the patient’s activity orders. Before intervening, the nurse must check the patient’s orders. For example, if the patient is on bed rest, the nurse will need to explain the use of a bedpan rather than helping the patient get out of bed to go to the bathroom. Interventions sometimes will be determined by orders and availability of resources. Asking for assistive personnel is appropriate after making sure the patient can get out of bed. If the patient is obese, the nurse will likely need assistance in getting the patient to the bathroom. Medicating the patient before checking the orders is not advised in this situation. Before medicating for pain, the nurse needs to perform a pain assessment. Offering the patient a walker is a premature intervention until the orders are verified.

500

Which of the following are direct care interventions? (Select all that apply.) a. Turning a patient b. Counseling a patient c. Performing resuscitation d. Documenting wound care e. Teaching wound care

What is a, b, c, e

Evaluation

100

The step of the nursing process where the nurse determines if the patient’s condition has improved and whether the patient has met expected outcomes? a. Assessment b. Planning c. Implementation d. Evaluation

What is d. evaluation In the five-step nursing process, the evaluation phase is the final step involving conducting evaluative measures to determine whether nursing interventions have been effective and whether the patient has met expected outcomes. Assessment, the first step of the process, includes data collection, validation, sorting, and documentation. Planning, the third step of the process, involves setting priorities, identifying patient goals and outcomes, and prescribing nursing interventions. During implementation, nurses initiate nursing care, which is necessary to help patients achieve their goals.

200

A nurse is getting ready to discharge to home a patient who has a nursing diagnosis of Impaired physical mobility. Before discontinuing the patient’s plan of care, what does the nurse need to do? a. Determine whether the patient has transportation to get home. b. Evaluate whether patient goals and outcomes have been met. c. Establish whether the patient has a follow-up appointment scheduled. d. Ensure that the patient’s prescriptions have been filled.

What is b. Evaluate whether patient goals and outcomes have been met. The nurse needs to evaluate whether goals and outcomes have been met before revising, continuing, or discontinuing a plan of care. The patient needs transportation, but that does not address the patient’s mobility status. Whether the patient has a follow-up appointment and ensuring that prescriptions are filled do not evaluate the problem of mobility.

300

What is the primary goal of outcomes management for professional nurses? a. To promote purposeful actions focused on improving a patient’s health condition b. To fine-tune nursing assessment skills c. To support the delegation of more nursing tasks to nursing assistive personnel d. To decrease the number of medication errors in nursing

What is a. To promote purposeful actions focused on improving a patient’s health condition The primary goal of outcomes management is to improve a patient’s health status. Assessment skills probably will be improved if a nurse focuses on improving patient outcomes, but this is not the primary goal. Delegating to nursing assistive personnel is not the primary goal of outcomes management. Reducing medication errors is a possible result of outcomes management, but it is not the primary goal.

400

The nurse is caring for a patient who has an open wound. When evaluating the progress of wound healing, what is the nurse’s priority action? a. Ask the nursing assistive personnel if the wound looks better. b. Document the progress of wound healing as “better” in the patient’s chart. c. Measure the wound and observe for redness, swelling, or drainage. d. Leave the dressing off the wound for easier access and more frequent assessments.

What is c. Measure the wound and observe for redness, swelling, or drainage. The nurse performs evaluative measures, such as completing a wound assessment, to evaluate wound healing. Nurses do not delegate assessment to nursing assistive personnel. Documenting “better” is subjective and does not objectively describe the wound. Leaving the dressing off for the nurse’s benefit of easier access is not a part of the evaluation process.

500

Identify elements of the evaluation process. (Select all that apply.) a. Setting priorities for patient care b. Collecting subjective and objective data to determine whether criteria or standards are met c. Ambulating 25 feet in the hallway with the patient d. Documenting findings e. Terminating, continuing, or revising the care plan

What is b, d, e