Chapter 09: Nursing Process

1.A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained. The nurse is currently involved in which step of the nursing process?

a.
Assessment
b.
Implementation
c.
Evaluation
d.
Diagnosing

ANS: A

Assessment is the deliberate and systematic collection of data about a patient. The data will reveal a patient’s current and past health status, functional status, and present and past coping patterns. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Implementation is the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care. Evaluation is crucial to deciding whether, after interventions have been delivered, a patient’s condition or well-being improves.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:124OBJ:Describe each step of the nursing process.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

2.The nurse is admitting a patient to the unit and asks the patient about the health history. The nurse is engaged in which component of the nursing process?

a.
Evaluation
b.
Diagnosis
c.
Assessment
d.
Planning

ANS: C

The nurse is in the assessment phase. An assessment database includes a patient’s comprehensive health history, which includes information about a patient’s physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system. The database also includes physical examination findings and a summary of results from laboratory and diagnostic testing. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Evaluation is crucial to deciding whether, after interventions have been delivered, a patient’s condition or well-being improves. Planning involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 124 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

3.A postoperative patient is continuing to have incisional pain. As part of the nurse’s assessment, the nurse notes that the patient is grimacing when he or she changes position. The patient’s grimace can be useful in the assessment and can be described as which of the following?

a.
Cue
b.
Inference
c.
Diagnosis
d.
Health pattern

ANS: A

Grimacing is a cue. A cue is information that a nurse obtains through use of the senses. An inference is your judgment or interpretation of these cues. Gordon’s functional health patterns are a type of database format to obtain a comprehensive assessment. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 125 OBJ: Explain the type of conclusions that result from data analysis.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

4.A postoperative patient has denied the need for pain medication. The nurse has noted that the patient describes the pain as a “1” on a 0 to 10 scale. The nurse also notes that the patient grimaces when he or she changes position and guards the incision. The nurse believes that the patient is experiencing pain based on the information gathered in the assessment. What is this phenomenon known as?

a.
Cue
b.
Inference
c.
Diagnosis
d.
Health pattern

ANS: B

The nurse made a judgment, which is an inference, that the patient is experiencing pain. An inference is a nurse’s judgment or interpretation of a cue. A cue is information that you obtain through use of the senses. Gordon’s functional health patterns are a type of database format to obtain a comprehensive assessment. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat such as impaired tissue perfusion.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 125 OBJ: Explain the type of conclusions that result from data analysis.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

5.A nurse is collecting data during the assessment of a patient. During the assessment, the nurse collects both subjective and objective data. Which information should the nurse consider as subjective data?

a.
Heart rate of 96
b.
Incisional erythema
c.
Emesis of 150 mL
d.
Sharp, burning pain

ANS: D

Sharp, burning pain is subjective. Subjective data are patients’ verbal descriptions of their health problems. Only patients provide subjective data. Heart rate, incisions, and emesis are all objective data. Objective data are observations or measurements of a patient’s health status.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 126 OBJ: Differentiate between subjective and objective data.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

6.The nurse has just completed an assessment on a patient with a fractured right femur. Which data will the nurse categorize as objective?

a.
The patient’s toes of right foot are warm and pink.
b.
The patient reports a dull ache in the right hip.
c.
The patient says feels tired all the time.
d.
The patient is concerned about insurance coverage.

ANS: A

Toes pink and warm are objective data. Objective data are observations or measurements of a patient’s health status. Subjective data are patients’ verbal descriptions of their health problems. Only patients provide subjective data.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 126 OBJ: Differentiate between subjective and objective data.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

7.A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a nurse. As the student nurse charts the interaction, which statement is the best way to document what happened?

a.
Appears to be in pain as evidenced by grouchy behavior
b.
Behavior is inappropriate, requests registered nurse do the assessment
c.
States, “I want a registered nurse to do my assessment”
d.
Is grumpy, registered nurse notified

ANS: C

When a nurse collects objective data, he or she should apply critical thinking intellectual standards (e.g., clear, precise, and consistent). Nurses do not include personal interpretive statements. The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care. If you do not report or record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient. Grouchy, inappropriate, and grumpy are personal interpretive statements and should be avoided.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:126 | 131

OBJ: Explain the relationship between critical thinking and steps of the nursing process.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

8.A mother of five children is admitted to the hospital for abdominal pain. The nurse asks a series of questions before performing a physical assessment. The patient answers the questions. When asking the patient some other questions, the patient’s spouse starts to answer. As the admission process progresses and the nurse gathers subjective data, the nurse requests that the patient answer the next questions. What is the rationale for the nurse’s behavior?

a.
The patient is exhibiting confusion.
b.
The spouse is being obnoxious.
c.
The patient is the best source of information.
d.
The spouse is too controlling.

ANS: C

A patient is usually the best source of information. A patient who is alert and answers questions appropriately provides the most accurate information about health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living. There is no evidence in the scenario to indicate confusion on the patient’s part or that the spouse was obnoxious or too controlling. The nurse needs more data before saying the spouse is obnoxious or controlling.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 127 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

9.A 2-year-old patient is being admitted to the outpatient surgery for a tonsillectomy. Which will provide the best primary source of information for what comforts the patient when stressed?

a.
Patient chart
b.
Patient
c.
Parents
d.
Surgeon

ANS: C

Family members and significant others are primary sources of information for infants, children, critically ill adults, patients with mental handicaps, or patients who are unconscious or have reduced cognitive function. The patient is too young. The patient’s chart is a source but not a primary source. The parents are a better source than the surgeon.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 127 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

10.A nurse is interviewing a patient being admitted to the hospital for surgery. During the interview, the nurse introduces self and explains that will be gathering some information. The nurse is in which phase of the interview?

a.
Orientation
b.
Working
c.
Assessment
d.
Termination

ANS: A

The orientation phase begins with introducing oneself and one’s position and explaining the purpose of the interview. The nurse explains to patients why the data are being collected and assures the patient that the information will remain confidential and will be used only by health care professionals who provide his or her care. During the working phase you gather information about a patient’s health status. When the interview comes to an end, this is called termination. Assessment is the first step in the nursing process, not the first step in an interview.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 128 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

11.A nurse is teaching the staff about the phases of the interview process. Which information should the nurse include in the teaching session?

a.
Orientation, working, termination
b.
Orientation, assessment, evaluation
c.
Planning, assessment, termination
d.
Planning, assessment, evaluation

ANS: A

The three phases of the interview process are orientation, working, and termination. Assessment, evaluation, and planning are phases in the nursing process.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 128-129 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

12.Which question or comment should the nurse initially use that would best gather the most information during a health history assessment?

a.
“Let us help you.”
b.
“Did you seek help when it first started?”
c.
“Tell me about the problems you are having.”
d.
“Do you have a family history of this problem?”

ANS: C

Initially use open-ended questions/comments. The use of open-ended questions/commentsprompts patients to describe a situation in more than one or two words. This technique leads to a discussion in which patients actively describe their health status. Once patients tell their story, focus on the symptoms that the patient identifies and ask closed-ended questions that limit his or her answers to one or two words such as “yes” or “no” or a number or frequency of a symptom. The questions that start with “Do” and “Did” are closed-ended. “Let us help you” will not get the patient’s perspective.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 129 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

13.As a nurse is obtaining a health history from a patient, the nurse uses comments such as “go on.” Which technique is the nurse using?

a.
Cues
b.
Inferences
c.
Back-channeling
d.
Termination

ANS: C

This is known as back-channeling, which is the practice of giving positive comments such as “all right,” “go on,” or “uh-huh” to the speaker. These indicate that a nurse has heard what the patient says and is attentive to hear the full story. A cue is information that you obtain through use of the senses. An inference is your judgment or interpretation of these cues. Termination is the last phase of the interview in which the interview comes to an end.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 129 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

14.A patient with a history of seizures is being admitted to the hospital after a grand mal seizure took place at a shopping mall. The patient’s spouse accompanied the patient to the hospital and is being interviewed by the nurse. Which question should the nurse ask to quickly focus on the patient’s symptoms?

a.
“What made you choose this hospital?”
b.
“How long did the seizure last?”
c.
“Tell me how the seizure disorder has affected the family.”
d.
“Tell me why you brought your spouse to the hospital today.”

ANS: B

“How long did the seizure last?” is the question that will quickly focus on the patient’s symptoms. Once patients tell their story, use a problem-seeking interview technique. This approach takes the information provided in the patient’s story and then more fully describes and identifies specific problem areas. For example, focus on the symptoms the patient identifies and ask closed-ended questions that limit the patient’s answers to one or two words such as “yes” or “no” or a number or frequency of a symptom. What made you choose this hospital does not focus on the seizure. “Tell me” will not get information quickly as these are open-ended.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 129 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control

15.A patient is admitted to the hospital after a motorcycle accident. The nurse in the emergency room is assessing vital signs, general appearance and behavior, and performing a head-to-toe examination of all body systems. What is the nurse doing?

a.
Making a medical diagnosis
b.
Performing a physical examination
c.
Making an evaluation
d.
Performing data validation

ANS: B

A physical examination involves use of the techniques of inspection, palpation, percussion, auscultation, and smell. A complete examination includes a patient’s height, weight, vital signs, general appearance and behavior, and a head-to-toe examination of all body systems. Nurses make nursing diagnoses, not medical diagnoses, after assessment of data. Evaluation is the last step of the nursing process. Evaluation is crucial to deciding whether, after interventions have been delivered, a patient’s condition or well-being improves. Validation of assessment data is the comparison of data with another source to confirm accuracy.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 129 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

16.When admitting a patient to the hospital, the nurse asks if has problems eating since the patient had a stroke. The patient denies any problems and states that does not require assistance. After lunch, the nurse notes that the patient has not eaten most of the food and has spilled much of the food. These cues lead the nurse to believe that the patient is not functioning at the level indicated upon admission. The nurse is using which type of information to make this deduction?

a.
Verbal behavior
b.
Physical assessment
c.
Nursing diagnosis
d.
Nonverbal behavior

ANS: D

Observation of the level of function is different from what a nurse learns about function during the interview. A nurse observes what the patient does, such as self-feeding or making a decision, rather than what the patient says he or she can do. The level of function involves a person’s ability to perform during everyday activities. Observation of the patient’s behavior for level of function differs from a physical assessment. The hands-on physical examination measures the extent of function through measures such as range of motion and muscle strength. Verbal behavior is what the patient says. A nursing diagnosis would be self-care deficit.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 129-130 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

17.A 67-year-old male patient of French heritage is admitted to the hospital. The patient is interviewed by a nurse from a Korean family. The nurse did not make eye contact with the patient while conducting the interview. This disturbed the patient because the patient thought that the nurse might be trying to hide something. Which factor most likely influenced the behavior of the nurse and patient?

a.
Culture
b.
Validation
c.
Collaborative problem
d.
Defining characteristics

ANS: A

Communication and culture are interrelated in the way individuals express feelings verbally and nonverbally. When a nurse learns the variations in how people of different cultures communicate, he or she will likely gather more accurate information from patients. Validation of assessment data is the comparison of data with another source to confirm accuracy. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status. Defining characteristics are the clinical criteria or assessment findings that support an actual nursing diagnosis.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 130 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

18.A nurse wants to provide patient-centered care to a patient of another culture. Which question is the most culturally sensitive when talking about a patient’s illness?

a.
“What do you call your problem?”
b.
“How long has your child had the runs?”
c.
“When did you last void today?”
d.
“Has anyone else in your family had diarrhea?”

ANS: A

To start an assessment, Seidel and others (2011) offer useful questions to begin to explore a patient’s illness or health care problem in context of the patient’s culture: “What do you call your problem?” A different culture may not know what “the runs” means. Most people do not know what void (urinate) means. Has anyone else in your family had diarrhea is not as culturally sensitive as finding out what the problem is according to the patient’s culture.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 130 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

19.Which action by the nurse is the final step in a complete assessment?

a.
Forming diagnostic conclusions
b.
Documentation of findings
c.
Auscultation
d.
Palpation

ANS: B

Communication of assessment findings, either verbally or through documentation, is the last step of a complete assessment. The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care. The techniques of a physical examination include inspection, palpation, percussion, auscultation, and smell. After reviewing and validating a patient’s assessment, the next step of the nursing process is to form diagnostic conclusions.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:131OBJ:Describe each step of the nursing process.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

20.A patient with bilateral pneumonia is admitted to the intensive care unit. The nurse who initially prepared the plan of care identified that the patient had the collaborative problem of Potential complications: hypoxemia. What made the nurse classify this as a collaborative problem?

a.
It requires ensuring adequate hydration.
b.
It requires monitoring for signs of acid-base imbalance.
c.
It requires evaluating the effects of positioning on oxygenation.
d.
It requires both nursing and physician-prescribed interventions.

ANS: D

A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status. When collaborative problems develop, nurses collaborate with personnel from other health care disciplines, such as social workers and dietitians and physicians. Adequate hydration, acid-base imbalance, and oxygenation do not make a collaborative problem.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 131 OBJ: Explain the type of conclusions that result from data analysis.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation

21.A patient states, “I’m burning up, and I have a fever.” The nurse takes the patient’s temperature, observes the skin for flushing, and feels the skin temperature. This is an example of __________ subjective data.

a.
validating
b.
clustering
c.
reviewing
d.
documenting

ANS: A

Validation of assessment data is the comparison of data with another source to confirm accuracy. The nurse reviews data to validate that measurable, objective physical findings support subjective data. A data cluster is a set of signs or symptoms that are grouped in a logical order. When a nurse reviews a patient’s subjective data, the nurse is examining the patient’s own interpretation of his or her condition. Documenting information includes the written details of the assessment.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 130 | 137 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

22.Upon assessment, the nurse finds that a patient has a heart rate of 66 beats per minute, a respiratory rate of 12 breaths per minute, and a blood pressure of 120/80 mm Hg. The nurse obtained which type of data?

a.
Personal
b.
Demographic
c.
Subjective
d.
Objective

ANS: D

Objective data are observations or measurements of a patient’s health status. Personal and demographic data refer to patient’s name, age, sex, and so on. Subjective data are patients’ verbal descriptions about their health problems. Demographic data includes birth, gender, address, family members’ names and addresses.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 126 OBJ: Differentiate between subjective and objective data.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care

23.A patient has lost 10 pounds in the last 2 months from breast cancer and chemotherapy. The chemotherapy has caused the patient to not eat. Which nursing diagnosis should the nurse use to develop the plan of care?

a.
Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Food Intake
b.
Imbalanced Nutrition: Less Than Body Requirements Related to Cancer
c.
Imbalanced Nutrition: Less Than Body Requirements Related to Loss of Weight
d.
Imbalanced Nutrition: Less Than Body Requirement Related to Insufficient Prescription of Chemotherapy

ANS: A

Imbalanced Nutrition: Less Than Body Requirement is the diagnostic label, whereas decreased food intake is the state of related factor(s) or etiology. The identification of a nursing diagnosis flows from the assessment and diagnostic process. Nursing diagnoses are worded in a two-part format: the diagnostic label followed by a statement of a related factor. Identify the patient’s response, not the medical diagnosis. Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. Breast cancer is a medical diagnosis. Identify the problem and etiology to avoid a circular statement. Such statements are vague and give no direction to nursing care. Less than body requirements and loss of weight is circular. Avoid legally inadvisable statements that imply blame, negligence, or malpractice. The diagnosis that states insufficient prescription of chemotherapy implies that the health care provider gave an inadequate prescription.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:135-136 | 137-139

OBJ: Describe the way in which defining characteristics and the etiological process individualize a nursing diagnosis. TOP: Nursing Process: Assessment

MSC: NCLEX: Management of Care

24.A nurse develops a nursing diagnosis for a patient. What is the rationale for the nurse’s actions?

a.
It allows a nurse to compete with physicians or health care providers.
b.
It allows a nurse to develop an individualized plan of care.
c.
It allows a nurse to treat nursing problems and medical problems.
d.
It allows a nurse to manage patient care for the entire health team.

ANS: B

The diagnostic process results in the formation of a total diagnostic statement that allows a nurse to develop an appropriate, patient-centered plan of care. A nursing diagnosis provides direction for nursing, not for medical problems or for the entire health team. It is not used to compete with physicians or health care providers.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 136 OBJ: List the steps of the nursing diagnostic process.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care

25.A patient is suffering from shortness of breath. How should the nurse write the expected outcome for this patient?

a.
“The patient will be comfortable by the morning.”
b.
“The patient will breathe unlabored at 14 to 18 breaths per minute by the end of the shift.”
c.
“The patient will not complain of breathing problems.”
d.
“The patient will appear less short of breath.”

ANS: B

Each patient outcome contains the following aspects in order to be correctly written: (1) patient-centered, (2) singular, (3) observable, (4) measurable, (5) time limited, (6) mutual factors, and (7) realistic. Comfortable is not measurable. Outcome that deals with no complaints of breathing is lacking the time limited guideline. “Patient will appear less short of breath” is not a correct statement because there is no specific observable behavior for “appears less short of breath.”

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:142

OBJ:Discuss the difference between a goal and an expected outcome.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care

26.A nurse is caring for a patient and performs several interventions. Which action by the nurse is an independent nursing intervention?

a.
Turning every 2 hours
b.
Administering a medication
c.
Inserting an indwelling catheter
d.
Starting an intravenous (IV) for intravenous fluids

ANS: A

According to state Nurse Practice Acts, independent nursing interventions pertain to ADLs (turning), health education and promotion, and counseling. Nurse-initiated interventions are the independent nursing interventions or actions that nurses initiate. Physician-initiated interventions are dependent nursing interventions or actions that require an order from a physician or another health care professional. Administering a medication, implementing an invasive procedure (catheter and intravenous fluids), and preparing a patient for diagnostic tests are examples of such interventions.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 143 OBJ: Discuss the process of selecting nursing interventions.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

27.A nurse is writing a care plan for a newly admitted patient. Which outcome statement did the nurse correctly write?

a.
“The patient will eat 80% of all meals.”
b.
“The nursing assistant will set up the patient for a bath every day.”
c.
“The nursing assistant will ambulate the patient three times a day by May 30.”
d.
“The patient will identify the need to increase dietary intake of fiber by July 4.”

ANS: D

The patient will identify the need to increase dietary intake of fiber by July 4 is measurable, reliable, valid, and focuses on the patient. Expected outcomes are measurable criteria to evaluate goal achievement. These measurable effects relate to a change in a patient’s physical condition or behavior that results from individualized nursing interventions. Outcomes should be measurable, reliable, valid, suited to the patient, and sensitive to change. Eat 80% of meals has no time frame. The nursing assistant is not the focus the patient is. Also, the nursing assistant will ambulate the patient or set the patient for a bath are interventions, not outcomes.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:141

OBJ:Discuss the difference between a goal and an expected outcome.

TOP: Nursing Process: Planning MSC: NCLEX: Management of Care

28.A home health nurse is providing care to a patient. Which action by the nurse is a physical care technique?

a.
Dressing a patient
b.
Assisting a patient to learn how to shop
c.
Performing range-of-motion exercises
d.
Administering cardiopulmonary resuscitation

ANS: C

Physical care techniques involve the safe and competent administration of nursing procedures (e.g., inserting a urinary catheter, performing range-of-motion exercises). Dressing a patient is an activity of daily living. Shopping is an instrumental activity of daily living. Cardiopulmonary resuscitation is a lifesaving measure.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 154 OBJ: Discuss the process of selecting nursing interventions.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

29.A nurse is delegating care of patients to the nursing assistant personnel (NAP) and a licensed practical nurse (LPN). Which situation indicates the nurse needs more instruction on delegation?

a.
LPN to change a sterile dressing
b.
NAP to provide skin care
c.
NAP to insert an indwelling catheter
d.
LPN to administer an enema

ANS: C

The question indicates the nurse made an incorrect delegation assignment. An NAP cannot insert indwelling catheter, an LPN or RN can do that skill. Noninvasive and frequently repetitive interventions such as skin care, ambulation, grooming, and hygiene measures are examples of activities that you assign to NAP such as certified nurse assistants. Licensed practical nurses perform these measures in addition to medication administration and many invasive tasks (e.g., dressing care and catheterization). It is appropriate for an RN to delegate, a sterile dressing change and enema to an LPN. It is appropriate for an RN to delegate skin care to an NAP.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 155 OBJ: Discuss the process of selecting nursing interventions.

TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care

30.A patient has an outcome of ambulating three times a day. The patient does not ambulate the entire day. What should the nurse do next?

a.
Walk the patient.
b.
Reassess the patient.
c.
Change the goal for the patient.
d.
Continue with the plan for the patient.

ANS: B

When there is failure to achieve a goal, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to discover changes the plan needs. A complete reassessment of all patient factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. The plan cannot continue because the goal was not met. The goal cannot be changed and walking the patient cannot occur until reassessment has been completed.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:157

OBJ: Describe how to evaluate nursing interventions selected for a patient.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

31.A patient has met the goals and outcomes mutually agreed upon for improvement of ventilatory status. What should the nurse do next?

a.
Modify the care plan.
b.
Discontinue the care plan.
c.
Create a nursing diagnosis that states goals have been met.
d.
Reassess the patient’s response to care and evaluate interventions.

ANS: B

After a nurse determines that expected outcomes and goals have been met and evaluation confirms it, the nurse discontinues that portion of the care plan. The nurse modifies a care plan when goals are not met. Create a nursing diagnosis occurs after assessment, not during evaluation. Reassessing the patient occurs if the goals are not met.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:157OBJ:Describe each step of the nursing process.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

32.A nurse is evaluating care for a patient. Which action should the nurse take?

a.
Compares patient findings with the goals and outcomes
b.
Determines if interventions were completed
c.
Develops a nursing diagnosis
d.
Writes a care plan

ANS: A

During evaluation you compare your findings with the goals and expected outcomes set for your patient. You conduct an evaluation to determine if expected outcomes are met, not if nursing interventions were completed. Develops a nursing diagnosis is the second step of the nursing process (diagnosis), not the last (evaluation). Writes a care plan occurs in the planning phase.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:156OBJ:Describe each step of the nursing process.

TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care

MULTIPLE RESPONSE

1.The nurse is beginning an assessment of a newly admitted patient. What are some recommended comprehensive assessment approaches the nurses can use? (Select all that apply.)

a.
Functional Health Patterns
b.
Nursing Diagnosis
c.
Problem-Focused Approach
d.
Nursing Intervention Classification
e.
Nursing Outcome Classification

ANS: A, C

There are two approaches for a comprehensive assessment. Gordon’s Functional Health Patterns involves use of a structured database format, based upon an accepted theoretical framework or practice standard. Another approach for conducting a comprehensive assessment is the problem-focused approach. The nurse should focus on the patient’s situation and begin with problematic areas. By using Nursing Intervention Classification nurses learn the common interventions recommended for the various NANDA-I nursing diagnoses. The Nursing Outcome Classification system is a classification system of nursing-sensitive outcomes. One of its purposes is to identify, label, validate, and classify nursing-sensitive patient outcomes. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat and occurs after assessment.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 125 OBJ: Discuss approaches to data collection in nursing assessment.

TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care