NCLEX PN Hill and Howlett Chapter 8: The Nursing Process Flashcards
When and for what reason did the nursing process originate?
A. 1900s—to develop nursing diagnoses
B. 1930s—to develop nursing diagnoses
C. 1950s—to provide structure for thinking in
nursing
D. 1970s—to provide structure for thinking in
nursing
C. The nursing process originated in the 1950s. It included four steps: data collection, planning, intervention, and evaluation.
Which of the following steps of the nursing process compares actual outcomes of nursing care to the expected outcomes?
A. Data collection
B. Planning
C. Implementation
D. Evaluation
D. Data collection is the systematic gateway and review of information. Planning involves assisting the RN in the development of nursing diagnosis, goals, and interventions. Implementation involves the provision of nursing care to accomplish client goals. Evaluation compares the actual outcomes of nursing care to expected outcomes.
Which of the following is subjective information from a client?
A. Pain
B. Blood pressure
C. Temperature
D. Weight
A. Pain is based on client’s opinion, thus subjective. On the other hand, B, C, and D, are objective because these can be observed and MEASURED.
Which of the following is objective information from a client?
A. Tenderness
B. Burning
C. Arrhythmia
D. Anxiousness
C. Arrhythmia can be observed and MEASURED via electrocardiogram. The rest are subjective and based on clients opinion.
Which of the following would be considered emergency data that need to be reported immediately?
A. A client has a temperature of 99° F.
B. A client reports midsternal chest pain.
C. A client has a rash.
D. A client reports diarrhea.
B. A temperature of 99° F is mildly elevated and does not require immediate reporting. Midsternal chest pain may indicate a heart attack (myocardial infarction) and needs to be reported immediately. A rash is troublesome to the client but generally does not need to be reported immediately. Diarrhea does not need to be reported immediately.
Which of the following would be an appropriate response from a nurse?
A. “Am I correct in saying that you are worried?”
B. “Everything will be OK.”
C. “Don’t worry about anything.”
D. “You know you shouldn’t smoke.”
A. Request clarification from the client to ensure understanding. Avoid telling clients what may not happen. Avoid telling clients not to worry, because clients need to work through their own emotions. Avoid verbalizing disapproval of clients.
A multidisciplinary care plan is most likely to be used in what type of setting?
A. Medical office
B. Intensive care unit
C. Obstetrics
D. Long-term care
D. Multidisciplinary care plans may be used in medical offices, intensive care units, and obstetrics, but they are not as common as in long-term care settings. Staff members from varied professions and disciplines are involved in the care of clients in long-term care facilities.
Which of the following is essential for the plan of care for a client?
A. Reporting of progress or lack of progress
B. Discussions with the team
C. Documentation of the plan of care
D. Participation in client care conferences
C. Reporting a client’s progress or lack thereof is important, but it must be documented. Discussion with team members is important, but it must be documented. Legally, if it was not charted, it was not done. Participation in client care conferences is important, but it must be documented.
Which of the following is the responsibility of practical nurses?
A. Choosing nursing interventions
B. Observing and reporting the results of an enema
C. Finalizing a nursing diagnosis
D. Measuring desired client outcomes
B. Observation is a form of data collection that is a responsibility of practical nurses. Practical nurses report their findings to the registered nurse. Choosing interventions, finalizing a diagnosis and measuring outcomes are responsibilities of a registered nurse.
A _______________________ is finalized by the registered nurse (RN), who uses NANDA-I as a source.
Nursing Dx
