Nursing Process- Foundation for Practice

1.

A modern approach to the development of clinical decisions and clinical judgments is the use of human patient simulators in simulation laboratories on campus. Human patient simulators are best described as
A)
Life-sized mannequins with a sophisticated computer interface
B)
Small doll-like devices used for measuring vital signs
C)
Healthcare equipment that has practice modes
D)
Life-saving equipment that resuscitates patients in cardiac arrest
Ans:
A

Feedback:

The human patient stimulator, a life-sized mannequin with a sophisticated computer interface, presents students with clinical scenarios that evolve based on decisions that students make.

2.

What is meant by intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new meanings and appreciations?
A)
Memorization
B)
Reflection
C)
Reminiscing
D)
Evangelization
Ans:
B

Feedback:

Reflection is defined as those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations.

3.

The nurse is caring for a newly admitted patient. How can a nurse arrive at a more complete database for this patient?
A)
Through clustering of data
B)
Analysis of lab values
C)
Review of the chart
D)
Consult with several sources
Ans:
D

Feedback:

By having a more complete database from several sources, including the patient, the nurse can arrive at a more accurate conclusion. The nurse can obtain data from secondary sources, such as family members, significant others, other healthcare professionals, health records, and literature review.

4.

A patient complains of weakness following his administration of insulin. The nurse decides to assess the patient’s blood sugar and prepare a snack in case the blood sugar is low. What action has the nurse implemented?
A)
Clinical reasoning
B)
Caring
C)
Reflection
D)
Assessment
Ans:
A

Feedback:

Clinical reasoning is the process of making a nursing judgement that will provide safe and quality care.

5.

A nursing student is caring for a patient who has diabetes mellitus. The patient takes insulin two times per day. Based on the student’s knowledge of insulin’s onset of action, he makes sure the patient’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 patient care.

6.

For the nursing student to implement the most effective care for her patients, she must
A)
Have rudimentary critical-thinking skills
B)
Apply preexisting knowledge
C)
Apply clinical knowledge to theoretic knowledge
D)
Establish a clinical log for evaluation
Ans:
B

Feedback:

To deal with the patient’s problems appropriately, the student nurse will need to use his or her knowledge base from previous classes.

7.

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.

8.

Which of the following learners enjoy learning that takes place in the clinical setting?
A)
Sequential thinkers
B)
Grade-oriented students
C)
Learning-oriented students
D)
Active experimenters
Ans:
D

Feedback:

Active experimenters enjoy clinical rotations and skills laboratories.

9.

A nurse is educating a pregnant woman in preterm labor on the use of her home monitoring equipment and her medications. What factor could impede the patient’s ability to learn?
A)
Preparation
B)
Intelligence
C)
Previous knowledge
D)
Anxiety
Ans:
D

Feedback:

Too much anxiety can paralyze high-order thinking skills.

10.

A patient 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 patient, she must first
A)
Implement critical-thinking skills
B)
Develop a relationship with the patient
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 patient care situations.

11.

The nurse assesses a patient’s blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. This nursing action is
A)
Evaluation
B)
Assessment
C)
Planning
D)
Implementation
Ans:
B

Feedback:

The nurse is collecting data when measuring the patient’s blood pressure. Collection of patient data is considered assessment regardless of when it occurs.

12.

When the nurse assesses the patient’s blood sugar, the type of skill that the nurse is using is termed?
A)
Technical
B)
Therapeutic
C)
Interactional
D)
Adaptive
Ans:
A

Feedback:

Technical skills are used to carry out treatments and procedures.

13.

When the nurse administers pain medication to a postoperative patient, the phase of the nursing process that is occurring is which of the following phases?
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.

14.

When the nurse is administering Lasix 20 mg to a patient in congestive 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.

15.

The functional health patterns provide the nurse with a(an)
A)
Framework for collecting assessment data
B)
Method for evaluation of diagnostic testing
C)
Preparation of diagnostic statements
D)
System for documenting patient care
Ans:
A

Feedback:

The functional health patterns provide a framework for the collection of assessment data.

16.

Clustering of data to ascertain a nursing diagnosis is accomplished through the use of:
A)
general systems theory process.
B)
problem-solving process.
C)
decision-making process.
D)
information-processing theory.
Ans:
D

Feedback:

Nurses use information-processing theory to help cluster data to arrive at a diagnosis.

17.

A nurse ascertains that the patient is showing signs and symptoms of dehydration due to nausea and vomiting. The nurse makes the patient NPO and calls the physician. The nursing action of making the patient NPO is
A)
General systems theory process
B)
Problem-solving process
C)
Decision-making process
D)
Information-processing theory
Ans:
C

Feedback:

Making decisions about patient care is the essence of nursing practice. Decision making is integral to every step of the nursing process.

18.

The information that enters the system or data collected during the assessment is considered to be the:
A)
input.
B)
immediate outcome.
C)
throughput.
D)
output.
Ans:
A

Feedback:

Input, the information that enters a system, is the data collected during the assessment step.

19.

Three weeks after surgery the nurse notes the patient 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 patient goals have been met.

20.

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 patient to reach maximum functional health.

21.

The nurse changes a patient’s surgical dressing daily. This is considered to be part of which phase of the nursing process?
A)
Nursing diagnosis
B)
Patient goal
C)
Outcome identification
D)
Implementation
Ans:
D

Feedback:

Implementation is the action phase of the nursing process.

22.

A written plan of care for each patient is required by what organization?
A)
The Joint Commission
B)
The National Institutes of Health
C)
The American Association on the Accreditation of Colleges of Nursing
D)
The American Nurses Association
Ans:
A

Feedback:

The patient plan of care is a written summary of care that a patient is to receive. The Joint Commission requires a written plan of care for each patient.

23.

When the nurse formulates three nursing diagnoses for an adult patient hospitalized for abdominal surgery, the nurse has focused on the patient’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.

24.

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 patients to identify goals and intervention strategies that will address identified problems.

25.

What is the primary goal of the planning phase of the nursing process?
A)
To identify goals for the patient
B)
To prepare a plan of care
C)
To establish priorities for care
D)
To acknowledge patient needs
Ans:
B

Feedback:

The planning phase involves preparing a patient plan of care, which directs the activities of the nursing staff in the provision of patient care.

26.

The nurse writes the following on the patient’s chart: The patient will have complete healing of the surgical incision on the right lower quadrant of the abdomen in 3 weeks. This is a(n)
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, patient-focused goals.

27.

Which organization defines the nursing diagnosis?
A)
American Nurses Association
B)
North American Nursing Diagnosis Association–International
C)
American Association of Colleges of Nursing
D)
Sigma Theta Tau International
Ans:
B

Feedback:

The North American Nursing Diagnosis Association–International defines the nursing diagnosis as “a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.”

28.

Which of the following healthcare professionals are licensed to make a nursing diagnosis?
A)
Licensed practical nurses
B)
Registered nurses
C)
Social workers
D)
Physicians’ assistants
Ans:
B

Feedback:

Registered nurses are educated and licensed to make nursing diagnoses.

29.

A patient has had an appendectomy. He has an incision at the right lower quadrant of the abdomen. Nurse has written: Alteration in skin integrity related to incision at right lower quadrant of the abdomen. This is
A)
A planned outcome
B)
Subjective data
C)
A nursing intervention
D)
An actual nursing diagnosis
Ans:
D

Feedback:

Diagnosing human responses to actual or potential health problems is the second phase of the nursing process.

30.

An in-depth history and physical builds the
A)
Plan of care
B)
Future interventions
C)
Database
D)
Secondary source
Ans:
C

Feedback:

An in-depth history and physical assessment are usually required at admission to a hospital or long-term care facility, or during the first visit by community or home health nurse.

31.

The nurse caring for a newly admitted patient recognizes that the patient’s past chart 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.

32.

A patient states, “I am having a severe headache with pain over my right eye.” This statement is classified as
A)
Primary source
B)
Objective data
C)
Symptom identification
D)
Planning care
Ans:
A

Feedback:

This patient is the primary source of information for assessment.

33.

Which of the following is a distinct nursing function in the nursing process?
A)
Assessment
B)
Planning
C)
Nursing diagnosis
D)
Evaluation
Ans:
C

Feedback:

In the 1980s, further support was gained for making diagnosis a distinct nursing function and a separate step of the nursing process. In the landmark Nursing: A Social Policy Statement, the ANA again identified diagnosis of actual and potential health problems as an integral part of nursing practice.

34.

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 patients.

35.

In 1955, Lydia Hall introduced the nursing process. Nursing care delivery changed based on
A)
Guidelines from the medical model
B)
Information from the scientific process
C)
The patient’s and nurse’s interaction
D)
The process of pathophysiology
Ans:
C

Feedback:

The nursing process is that which goes on between a patient and a nurse in a given setting; it records the behaviors of patient and nurse and the resulting interaction.