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1. Based on the work of Marjory Gordon and the nursing process, which component is associated with problem identification?
A) Assessment
B) Outcome projection
C) Intervention
D) Outcome evaluation
Ans: A
Feedback:
According to Marjory Gordon, the nursing process is a method of problem identification and problem-solving. She viewed assessment and diagnosis as the problem-identification components. Outcome projection, intervention, and outcome evaluation are the problem-solving components.
14. A nursing student is developing interpersonal skills. Which method would best
facilitate this type of learning?
A) Actively reading the assigned text
B) Writing extensive nursing plans of care
C) Participating in communication courses
D) Practicing in the skills lab
Ans: C
Feedback:
Interpersonal skills are gained in the communication courses, group work, and the clinical setting during work with the patient, instructor, and other healthcare professionals. Technical skills and experiential knowledge are gained in nursing school in the laboratory and clinical setting. Theoretical knowledge is acquired by active reading, writing, and studying for nursing courses.
11. A client had surgery 3 weeks ago, and now the nurse notes that the client has partial healing of the surgical wound. This assessment would occur in which phase of the nursing process?
A) Outcome
B) Nursing diagnosis
C) Planning
D) Evaluation
Ans: D
Feedback:
In the evaluation phase, nurses collect data to determine if client goals have been met.
22. What type of learning best takes place in the nursing laboratory?
A) Kinesthetic learning
B) Auditory learning
C) Concrete learning
D) Collaborative learning
Ans: A
Feedback:
Learning in the clinical setting or nursing laboratory may be more active, kinesthetic, and random.
13. A nurse ascertains that the client is showing signs and symptoms of dehydration due to nausea and vomiting. The nurse makes the client n.p.o. (nothing by mouth) and calls the physician. The nursing action of making the client n.p.o. is the result of:
A) general systems theory process. B) general adaptation theory.
C) decision-making process.
D) information-processing theory.
Ans: C
Feedback:
Making decisions about client care is the essence of nursing practice. Decision-
making is integral to every step of the nursing process. The systematic processing of nursing information is not characterized as information-processing theory, general systems theory, or general adaptation theory.
8. When the nurse formulates three nursing diagnoses for an adult client hospitalized for abdominal surgery, the nurse has focused on the client's:
A) medical record.
B) actual health problems.
C) medical diagnosis.
D) past medical history.
Ans: B
Feedback:
Formulating the diagnostic statement requires knowledge of the differences among actual, risk, possible, and wellness nursing diagnoses.
5. The nurse writes the following on the client's chart: The client will show complete healing of the surgical incision on the right lower quadrant of the abdomen in 3 weeks. This is a(an):
A) nursing diagnosis.
B) assessment.
C) evaluation.
D) outcome identification.
Ans: D
Feedback:
According to the ANA's Nursing: Scope and Standards of Practice, outcome identification refers to formulating and documenting measurable, realistic, client- focused goals.
24. A nursing student is caring for a client who has diabetes mellitus. The client takes insulin two times per day. Based on the student's knowledge of insulin's onset of action, the student makes sure the client's meals arrive in coordination with the insulin's effect. The knowledge used by the student is:
A) evaluative.
B) lacking.
C) integrated.
D) creative
Ans: C
Feedback:
This scenario indicates the integration of a student's knowledge in the provision of safe client care.
6. What is the primary goal of the planning phase of the nursing process?
A) To identify goals for the client
B) To prepare a plan of care
C) To establish priorities for care
D) To acknowledge client needs
Ans: B
Feedback:
The planning phase involves preparing a client plan of care, which directs the activities of the nursing staff in the provision of client care.
19. A client who has limited finances and limited capacity for education requires home healthcare for a chronic illness. For the nurse to provide a high level of care to this client, which action would the nurse do first?
A) Implement critical-thinking skills.
B) Develop a relationship with the client.
C) Engage the services of a social worker.
D) Determine what care has been provided.
Ans: A
Feedback:
Critical thinking requires nurses to choose solutions or identify options for client care situations.
16. When the nurse administers pain medication to a postoperative client, the phase of the nursing process that is occurring is:
A) assessment.
B) nursing diagnosis.
C) planning.
D) implementation.
Ans: D
Feedback:
Implementation refers to the action phase of the nursing process, in which nursing care is provided.
21. A nursing student is working on using critical thinking skills to develop expertise. The student is applying information learned from instructors, clinical laboratory skills, and textbook readings. The student is at which level of expertise? A) Novice
B) Advanced beginner
C) Competence
D) Expert
Ans: A
Feedback:
The first stage is novice, in which learners use rules to guide practice. Examples of such rules include information and skills learned from instructors, practice in laboratory, and read in books. Advanced beginner is the next stage. After more experience in clinical situations, nurses learn to consider more facts and complex rules. At competence, nurses devise new rules and reasoning procedures. They feel responsible for the outcomes and may question rules. Nurses gain competence through more experience. last stage is expert. The expert knows the goal to achieve and how to achieve it. The best experts think before they act. They intuitively use sound theoretical thinking to reflect on the goal and decide on the seemingly appropriate action
2. Based on the work of Marjory Gordon and the nursing process, which component is associated with problem identification?
A) Assessment
B) Outcome projection
C) Intervention
D) Outcome evaluation
Ans: A
Feedback:
According to Marjory Gordon, the nursing process is a method of problem identification and problem-solving. She viewed assessment and diagnosis as the problem-identification components. Outcome projection, intervention, and outcome evaluation are the problem-solving components.
17. When the nurse assesses the client's blood sugar, what is the term for the type of skill the nurse is using?
A) Technical
B) Therapeutic
C) Interactional
D) Adaptive
Ans: A
Feedback:
Technical skills are used to carry out treatments and procedures.
9. The nurse changes a client's surgical dressing daily. This is considered to be part of which phase of the nursing process?
A) Nursing diagnosis
B) Client goal
C) Outcome identification
D) Implementation
Ans: D
Feedback:
Implementation is the action phase of the nursing process.
4. Which healthcare professional is licensed to make a nursing diagnosis? A) Licensed practical nurse
B) Registered nurse
C) Social worker
D) Physician assistant
Ans: B
Feedback:
Registered nurses are educated and licensed to make nursing diagnoses.
2. The term nursing process is synonymous with the:
A) identification of health problems.
B) verification of wellness issues.
C) application of nursing diagnosis.
D) problem-solving approach.
Ans: D
Feedback:
The term nursing process is synonymous with the problem-solving approach for discovering the healthcare and nursing care needs of clients.
15. When the nurse is administering furosemide 20 mg to a client with heart failure, what phase of the nursing process does this represent?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
Ans: C
Feedback:
Implementation refers to the action phase of the nursing process, in which nursing care is provided.
20. A nurse is integrating knowledge learned in the classroom with a clinical client situation. The nurse is using which skill?
A) Communication
B) Clinical reasoning
C) Collaboration
D) Active listening
Ans: B
Feedback:
Clinical reasoning is used when applying critical thinking, which integrates knowledge that until this point had been theoretical, to an actual patient scenario. Communication involves both speaking and writing, including documentation. Collaboration involves communicating with other members of the healthcare team. Active listening implies that nurses are responsive to the cues that patients are sending.
23. In order to implement the most effective care for clients, a nursing student must:
A) have expert-level critical-thinking skills.
B) apply preexisting knowledge to present situations.
C) replace theoretic knowledge with practical knowledge.
D) maintain a detailed clinical log for evaluation.
Ans: B
Feedback:
To deal with the client's problems appropriately, the student nurse will need to use her knowledge base from previous classes. Critical thinking skills are necessary, but these do not have to be at an expert level. Theoretic and practical knowledge are complementary, not contradictory. A clinical log does not ensure effective care.
18. The nurse assesses a client's blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. What action has the nurse implemented?
A) Evaluation
B) Appraising
C) Planning
D) Implementation
Ans: A
Feedback:
The nurse is collecting data to evaluate the effectiveness of a medication that was administered. This does not involve planning or implementation. Appraising is not a discrete part of the nursing process.
12. A nurse is conducting an assessment of a client. Which information would the nurse identify as a primary source?
A) Client’s complaints about abdominal pain at a rating of 8
B) Family member’s report of client’s pain level
C) Phone call with client’s primary practitioner about admission
D) Test results from a previous admission
Ans: A
Feedback:
The patient is the primary source of information for assessment. Secondary sources include family members, significant others, other healthcare professionals, health records, and literature review.
7. After the nurse has formulated expected outcomes, the next step of the nursing process is to:
A) outline evaluation strategies.
B) prepare an oral report.
C) document the rationale.
D) write the plan of care.
Ans: D
Feedback:
Nurses work together with clients to identify goals and intervention strategies that will address identified problems.
3. The nurse caring for a newly admitted client recognizes that the client's past medical record from previous admissions at an acute care facility is considered to be the:
A) primary source.
B) secondary source.
C) subjective data.
D) nursing diagnosis.
Ans: B
Feedback:
Secondary sources include family members, significant others, other healthcare professionals, health records, and literature review.
10. Nursing actions should be:
A) associated with the family.
B) goal-directed.
C) individually attained.
D) evaluated by team members.
Ans: B
Feedback:
Nursing actions are goal-directed, assisting the client to reach maximum functional health.