Chapter 5

Question 1

What best defines the nursing process?
a. A method to ensure that the health care provider’s orders are implemented correctly.
b. A series of assessments that isolate a patient’s health problem.
c. A framework for the organization of individualized nursing care.
d. A preset formula for the design of nursing care.

Answer 1

c. A framework for the organization of individualized nursing care.

Question 2

All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment?
a. 53-year-old admitted with a perforated ulcer
b. 5-year-old admitted for the implant of grommets in the middle ear
c. 76-year-old admitted for a knee replacement
d. 40-year-old admitted for possible bowel obstruction

Answer 2

a. 53-year-old admitted with a perforated ulcer

Question 3

What subjective data does the nurse record following a head-to-toe examination? a. Rash on back
b. Prolonged nausea
c. Blood pressure of 190/100
d. White blood cell count of 19,000

Answer 3

b. Prolonged nausea

Question 4

What objective data should the nurse include after a patient assessment?
a. Headache of 3 days’ duration
b. Severe stomach cramps
c. Flatulence
d. Anxiety

Answer 4

c. Flatulence

Question 5

When the nurse is prioritizing care during the planning phase of the nursing process, what is the guiding framework?
a. Primary
b. Secondary
c. Unreliable
d. Biased

Answer 5

b. Secondary

Question 6

What are the two primary methods used to collect data?
a. Written report by patient and family
b. Review of the chart and the nurse’s notes
c. Interview and physical examination
d. Review of the health care provider’s orders and the Kardex

Answer 6

c. Interview and physical examination

Question 7

The nurse writes two patient problems: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses?
a. The second diagnosis needs no defined nursing interventions.
b. The second diagnosis needs medical intervention.
c. The second diagnosis will not need to be evaluated.
d. The second diagnosis reflects a problem that does not yet exist.

Answer 7

d. The second diagnosis reflects a problem that does not yet exist.

Question 8

What framework does the establishment of priorities of care during the planning phase of the nursing process often use?
a. Erikson’s developmental tasks
b. Piaget’s cognitive table
c. Maslow’s hierarchy of needs
d. Freud’s classifications

Answer 8

c. Maslow’s hierarchy of needs

Question 9

What is an appropriate outcome statement for a patient with a patient problem of ineffective airway clearance related to thick secretions?
a. The patient will increase intake to 1000 mL daily to liquefy secretions.
b. The patient will cough more frequently within 3 days.
c. The patient will breathe better within 3 days.
d. The patient will perform deep-breathing exercises four times daily.

Answer 9

a. The patient will increase intake to 1000 mL daily to liquefy secretions.

Question 10

What is the primary purpose of nursing interventions?
a. To support health care provider’s orders
b. To provide direction for all caregivers
c. To provide broad, general statements
d. To clarify nursing principles

Answer 10

b. To provide direction for all caregivers

Question 11

What documentation reflects implementation?
a. “Patient selected low-sugar snacks independently.”
b. “Patient was medicated with Tylenol 500 mg PO for pain.”
c. “Patient was ambulated for 15 minutes after lunch.”
d. “Patient participated in group therapy session without reminder.”

Answer 11

c. “Patient was ambulated for 15 minutes after lunch.”

Question 12

Which nursing intervention is complete and correct?
a. “May 10: Unlicensed assistive personnel will ambulate patient. A. Nurse”
b. “Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse”
c. “Unlicensed assistive personnel will serve 8 oz glass of juice at each meal, 5/10.”
d. “P.M. nurse will ensure that heel protectors are in place before bedtime.”

Answer 12

“Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse”

Question 13

A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred?
a. Omission
b. Variance
c. Failure
d. Error

Answer 13

b. Variance

Question 14

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this datarepresent?
a. Symptoms
b. Data clustering
c. Signs of fluid overload
d. Urinary retention

Answer 14

b. Data clustering

Question 15

What type of assessment is performed continuously throughout nurse-patient contact?
a. Complete
b. Body systems
c. Focused
d. Subjective

Answer 15

c. Focused

Question 16

What assists the nurse in the identification of patient problems?
a. Objective data
b. Subjective data
c. Data clustering
d. Validated data

Answer 16

c. Data clustering

Question 17

What organized approach might the nurse use when performing a complete physical examination?
a. Maslow’s hierarchy of needs
b. A head-to-toe assessment
c. Subjective data collection
d. Objective data collection

Answer 17

b. A head-to-toe assessment

Question 18

Who is the person responsible for analyzing and interpreting data to arrive at a patient problem?
a. Health care provider
b. LPN/LVN
c. RN
d. Technician

Answer 18

c. RN

Question 19

What is the basis for designing and selecting nursing interventions to meet patient needs?
a. Patient problem
b. Care plan
c. Health care provider’s orders
d. Nurse’s notes

Answer 19

a. Patient problem

Question 20

The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation?
a. Contributing to the patient’s recovery
b. A risk factor
c. Difficult to maintain
d. A nursing responsibility

Answer 20

b. A risk factor

Question 21

What is a patient problem considered lacking?
a. A syndrome patient problem
b. An actual patient problem
c. A “risk for” diagnosis
d. A possible patient problem

Answer 21

d. A possible patient problem

Question 22

In which phase of the nursing process does the nurse select interventions to assist the patient to meet the needs demonstrated?
a. Assessment
b. Planning
c. Implementation
d. Evaluation

Answer 22

b. Planning

Question 23

What is an important consideration when developing the care plan?
a. Ensure the number of interventions is limited.
b. Ensure the patient is involved in the process.
c. Ensure interventions will be easy to implement.
d. Ensure evaluation of the patient problems is possible.

Answer 23

b. Ensure the patient is involved in the process.

Question 24

From where are the “risk for” patient problems identified?
a. The care plan
b. The interventions
c. The assessment
d. The evaluation

Answer 24

c. The assessment

Question 25

What expected outcome exemplifies accepted criteria?
a. Nurse will assess vital signs every day
b. Resident will observe safety guidelines while smoking
c. Resident will take part in one activity daily for the next 90 days
d. Nurse will monitor O2 saturation to maintain at greater than 90%

Answer 25

c. Resident will take part in one activity daily for the next 90 days

Question 26

During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
a. The patient complains of nausea.
b. The patient is vomiting.
c. The patient experiences tachycardia.
d. The patent is pacing the halls.

Answer 26

a. The patient complains of nausea.

Question 27

During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
a. The patient is asleep.
b. The patient is tearful.
c. The patient has facial grimacing.
d. The patient states, “I hurt all over.”

Answer 27

d. The patient states, “I hurt all over.”

Question 28

During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
a. The patient is coughing.
b. The patient has cyanosis of the lips.
c. The patient experiences tachypnea.
d. The patient complains of generalized discomfort.

Answer 28

d. The patient complains of generalized discomfort.

Question 29

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
a. The patient complains of chest pain.
b. The patient states, “I feel nauseous.”
c. The patient complains of feeling faint.
d. The patient is short of breath on exertion.

Answer 29

d. The patient is short of breath on exertion.

Question 30

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
a. The patient is jaundiced.
b. The patient states, “I am nervous.”
c. The patient complains of palpitations.
d. The patient denies dizziness when ambulating.

Answer 30

a. The patient is jaundiced.

Question 31

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
a. The patient complains of feeling depressed.
b. The patient states, “I hear voices in my head.”
c. The patient complains of auditory hallucinations.
d. The patient is pacing back and forth while chanting.

Answer 31

d. The patient is pacing back and forth while chanting.

Question 32

What is an example of an appropriate Patient problem?
a. Impaired skin integrity
b. Skin breakdown noted
c. Turn patient every 2 hours
d. The patient has scabies on his back

Answer 32

a. Impaired skin integrity

Question 33

What is an example of an appropriate patient problem?
a. Constipation
b. Patient complains of constipation
c. Need for laxatives
d. Patient has a duodenal ulcer

Answer 33

a. Constipation

Question 34

A nurse is formulating a patient problem. What is an example of an appropriately written patient problem?
a. Risk for impaired skin integrity related to physical immobilization
b. Physical immobilization secondary to risk for impaired skin integrity
c. Risk for impaired skin integrity related to diagnosis of decubitus ulcers d. Physical immobilization secondary to decreased cognitive ability

Answer 34

a. Risk for impaired skin integrity related to physical immobilization

Question 35

Which is an example of a patient problem?
a. Pneumonia
b. Diabetes mellitus
c. Impaired skin integrity
d. Congestive heart failure

Answer 35

c. Impaired skin integrity

Question 36

Which is an example of a medical diagnosis?
a. Constipation
b. Diabetes mellitus
c. Impaired skin integrity
d. Altered nutrition: less than body requirements

Answer 36

b. Diabetes mellitus

Question 37

Which is an example of a medical diagnosis?
a. Pain
b. Anxiety
c. Pneumonia
d. Impaired skin integrity

Answer 37

c. Pneumonia

Question 38

Which are acceptable secondary sources for data? (Select all that apply.)
a. Patient
b. Family members
c. Other health professionals
d. Diagnostic reports
e. Textbooks

Answer 38

B,C,D,E

Question 39

Which are official categories of patient problems? (Select all that apply.) a. Actual
b. Risk
c. Wellness
d. Syndrome

Answer 39

A.B,C,D

Question 40

Which are considered phases of the nursing process? (Select all that apply.) a. Diagnosis
b. Prediction
c. Assessment
d. Evaluation
e. Implementation
f. Outcome identification

Answer 40

A,C,D,E,F