Nursing Process

Question 1

Assessing

Answer 1

the nurse collects data

Question 2

Planning

Answer 2

Prioritizes

Develops strategies to resolve or decrease the patient’s problem

Question 3

Diagnoses

Answer 3

Identifies human responses to actual or potential health problems
ie at risk for, inability to

Question 4

Evaluation

Answer 4

Determines effectiveness of plan of care

Question 5

DVT

Answer 5

Venous inflammation and clot formation impedes blood flow

Question 6

Client w/ sleep distrubance

Answer 6

normal sleep aids - pillows, back rubs, snack - simplest interventions

Question 7

Maslow’s 1st priority

Answer 7

physiological - breathing, food, water, sex, sleep, homeostasis, elimination/excretion

Question 8

Maslow’s 2nd priority

Answer 8

Safety - security of body, employment, resources of the - morality, family, healthy, property

Question 9

Maslow’s 3rd priority

Answer 9

Love/belonging - friendship, family, sexual intimacy

Question 10

Maslow’s 4th priority

Answer 10

Esteem - confidence, achievement, respect

Question 11

Maslow’s 5th priority

Answer 11

Self Actualization - morality, creativity, problem solving

Question 12

When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of a patient?

Answer 12

Review the defining characteristics:
The first thing a nurse should do to differentiate is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.

Question 13

The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to:

Answer 13

Identify important data

This is the primary purpose of a nursing admission assessment.

Question 14

The guidelines for writing an appropriate nursing diagnosis include all of the following except:
A. State the diagnosis in terms of a problem, not a need
B. Use nursing terminology to describe the patient’s response
C. Use statements that assist in planning independent nursing interventions
D. Use medical terminology to describe the probable cause of the patient’s response

Answer 14

Answer- D

Rationale- A nursing diagnosis is a statement about a patient’s actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never part of the nursing diagnosis.

Question 15

Independent nursing interventions commonly used for immobilized patients include all of the following except:
A. Active or passive ROM exercises, body repositioning, and ADLs as tolerated
B. Deep-breathing and coughing exercises with change of position every 2 hours
C. Diaphragmatic and abdominal breathing exercises
D. Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy

Answer 15

Answer: D

Rationale- A, B, & C are incorrect. These are not independent nursing interventions because they require a physician’s order.

Question 16

The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply.

A. Collect and organize client information
B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses
E. Develop client goals

Answer 16

B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses

Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase.

Question 17

Assessment Phase

Answer 17

First Step
gathers information about a patient’s psychological, physiological, sociological, and spiritual status
Patient interview
Physical examinations
Referencing a patient’s health history, obtaining a patient’s family history, and general observation
Patient interaction is generally the heaviest during this evaluative phase

Question 18

Diagnosing Phase

Answer 18

Making an educated judgment about a potential or actual health problem with a patient
Multiple diagnoses are sometimes made
An actual description of the problem (e.g. sleep deprivation) & whether or not a patient is at risk of developing further problems
Used to determine a patient’s readiness for health improvement
Whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment.

Question 19

Diagnosing Phase

Answer 19

Making an educated judgment/inference about a potential or actual health problem with a patient (they are hypertensive)
Multiple diagnoses are sometimes made
An actual description of the problem (e.g. sleep deprivation) & whether or not a patient is at risk of developing further problems
The problem part of a nursing diagnosis should state the client’s response to a life process, event, or stressor
Used to determine a patient’s readiness for health improvement
Whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment.

Question 20

Planning Phase

Answer 20

1. Plan is developed
2. List of priorities is made
3. Goals are created: clear, measurable
4. Expected beneficial outcomes created
   Refer to the evidence-based Nursing Outcome Classification (set of standardized terms and measurements for tracking patient wellness)
   The Nursing Interventions Classification may also be used as a resource for planning.

Question 21

Implementing Phase

Answer 21

Follow through/coordinating the decided plan of action
potentially w/ other disciplines to ensure pt.’s safety Specific to each patient and focuses on achievable outcomes
Monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for follow-up
Can take place over the course of hours, days, weeks, or even months.

Question 22

Outcomes

Answer 22

Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. They should also be realistic and achievable.
consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior.

Question 23

A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client’s progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write?

A. Client understands the signs of impaired circulation
B. Goal met: Client cited numbness and tingling as sign of impaired circulation
C. Goal not met: Client able to name only two signs of impaired circulation
D. Goal not met: Client unable to describe signs of impaired circulation

Answer 23

C. Goal not met: Client able to name only two signs of impaired circulation

Rationale: The goal has not been met because the client states only two out of three signs of impaired circulation. By comparing the data with the expected outcomes, the nurse judges that while there has been progress toward the goal, it has not been completely met. The care plan may need to be revised or more effective teaching strategies may need to be implemented to achieve the goal.

Question 24

A client centered goal is a specific and measurable behavior or response that reflects a client’s:

Answer 24

Highest possible level of wellness and independence in function.

Question 25

The nurse is most likely to collect timely, specific information by asking which of the following questions?

Answer 25

“Would you describe what you are feeling?”

This is an open-ended question that will elicit subjective data. The data collected will reflect the client’s current health status and human response(s) and should generate specific information that can be used to identify actual and/or potential health problems.

Question 26

he nurse needs to validate which of the following statements pertaining to an assigned client?

A. The client has a hard, raised, red lesion on his right hand.
B. A weight of 185 lbs. is recorded in the chart
C. The client reported an infected toe
D. The client’s blood pressure is 124/70. It was 118/68 yesterday.

Answer 26

The client reported an infected tow

Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse should assess the client’s toe to validate the statement.