Nursing Process

1. Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. This characteristics of the nursing process is described as: A. Systematic B. Dynamic C. Interpersonal D. Outcome Oriented Answer: The correct answer is B. The term dynamic is used to describe the fact that there is much interaction and overlap among the five steps of the nursing process. 2. A patient complains about feeling nauseated after lunch. This is an example of what type of data? A. Subjective B. Objective C. Signs and Symptoms D. Overt Answer: The correct answer is A. A patient report of feeling nauseated cannot be perceived by the nurse and this is subjective data. 3. You are surprised to detect an elevated temperature (102 F) in a patien scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. The first thing you do is to: A. Inform the charge nurse B. Inform the surgeon C. Validate your finding D. Document your finding Answer: The correct answer is C. You should first validate your finding if it is unusual, deviates from normal, and is unsupported by other data. 4. When you receive shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. You should: A. Correct the initial assessment form B. Redo the initial assessment and document current findings C. Conduct and document an emergency assessment D. Perform and document a focused assessment on skin integrity Answer: The correct answer is D. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stand as is and cannot be redone.

5. When you enter the patients room to begin your nursing history, the patients wife is there. You should: A. Introduce yourself to both and thank the wife for being present. B. Introduce yourself to both and ask the wife if she wants to remain. C. Introduce yourself to both and ask the wife to leave. D. Introduce yourself and ask the patient if he would like the wife to remain. Answer: The correct answer is D. Since the patient has the right to indicate who he would like to be present for the nursing history exam. You should neither presume that he wants his wife to be there. 6. Identify all of the following that are purposes of diagnosing. The purpose of diagnosing is to identify: (1) How an individual, group, or community responds to actual or potential health and life processes. (2) Factors that contribute to or cause health problems (etiologies) (3) Strengths the patient can draw on to prevent or resolve problems (4) Nursing interventions to resolve health problems a. (1) and (2) b. (3) and (4) c. (1), (2) and (3) d. All of the above Answer: the correct answer is C. identifying nursing interventions to resolve health problems is done during the planning step of the nursing process 7. The terms diagnose and diagnosis has legal implications. They imply that there is a specific problem that requires management by a qualified expert. Which of the following statements is false? a. If you make a diagnosis, it means that you accept accountability for accurately naming and managing the problem. b. If you treat a problem or allow a problem to persist without ensuring the correct diagnosis has been made, you may cause harm and be accused of negligence c. You are accountable for detecting, identifying, or recognizing signs and symptoms that may indicate problems beyond your expertise d. When nurses diagnose a medical problem, they are just as accountable as physicians for detecting, identifying and managing the signs and symptoms of disease. Answer: the correct answer is D. while nurses are accountable to identify and document nursing diagnoses and the signs and symptoms suggestive of medical and collaborative problems, their responsibility for medical problems is related only to the scope of their practice and they do not share the same responsibility as their physician colleagues. 8. Altered health maintenance is an example of: a. Collaborative problem b. Interdisciplinary problem

c. Medical problem d. Nursing problem Answer: the correct answer is D, Nursing problem, because it describes a problem that can be treated by nurses within the scope of independent nursing practice. 9. A school nurse notices that Abel is losing weight and wants to perform a focused assessment on Abels nutritional status, fearing that she might have an eating disorder. How should the nurse proceed? A. Perform the focused assessment. This is independent nurse-initiated intervention. B. Request an order from Abels physician since this is a physician-initiated intervention C. Request an order from Abels physician since this is a collaborative intervention. D. Request an order from the nutritionist since this is a collaborative intervention Answer: The correct answer is A. This is an independent nurse-initiated intervention. The nurse therefore does not need an order from the physician or the nutritionist. 10. You are a brand new RN. When you orient to a new nursing unit that is currently understaffed, you are told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response? A. Allow the UAPs to do the admission assessment and report the findings to you. B. Do you own admission assessments but dont interfere with the practice if other professional RNs seem comfortable with the practice C. Tell the charge nurse that you are choosing not to delegate the admission assessment at this time until you can get further clarification from admission. D. Contact your labor representative and complain. Answer: The correct answer is C. You do not delegate this nursing admission assessment because you learned that only nurses can perform this intervention. You should seek clarification for this policy from nursing administration. 11. Niccon is a college student who wants to lose 20 pounds. She meets with the student health nurse and develops a plan to increase her activity level and decrease the consumption of wrong types of food and calories. The nurse plans to evaluate her weight loss monthly. When Niccon arrives for her first weigh-in, the nurse discovers that instead of the projected weight loss of 5 pounds, Niccon has only lost 1 pound. Which is the best nursing response? a. Congratulate Niccon and continue the plan of care. b. Terminate the plan of care since it is not working. c. Try giving Niccon more time to reach the targeted outcome. d. Modify the plan of care after discussing possible reasons for Niccons partial success. Answer: The correct answer is D. Since Niccon has only partially met her outcome, the nurse should first explore the factors making it difficult for Niccon to reach her outcome and then modify the plan of care.

12. The following are all classic elements of evaluation. Which item below places them in their correct sequence? (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting your judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what you are looking for when you evaluate, eg. Expected patient outcomes) a. (1), (2), (3), (4), (5) b. (3), (2), (1), (4), (5) c. (5), (2), (1), (3), (4) d. (2), (3), (1), (4), (5) Answer: The correct answer is C 13. When a new nurse is oriented to the sub-acute unit, she is told that each nurse is expected to observe her patients at least every hour, and more if their condition warrants extra monitoring. This expectation is best termed: a. Standard b. Criteria c. Custom d. Order Answer: The correct answer is A. Standard, the levels of performance accepted and expected by the nursing staff or other health team members. 14. Remember Niccon, the college student who wants to lose 20 pounds? When the nurse weighs her during the 5th step of the nursing process, what is she doing? a. Collecting assessment data to identify health problems b. Collecting assessment data to identify patient strengths c. Collecting evaluative data to justify terminating the plan of care d. Collecting evaluative data to measure outcome achievement Answer: The correct answer is D. collecting evaluative data to measure outcome achievement. 15. One of the outcomes Niccon and the nurse planned is that Niccon appreciates or values a healthy body efficiently to try new behaviors. This outcome is best described as: a. Cognitive b. Psychomotor c. Affective d. Physical change Answer: The correct answer is C. Affective outcomes pertain to changes in patient values, beliefs, and attitudes. 16. Mr. Esquieres tells the nurse he fears becoming hooked on drugs and consequently waits until his pain becomes unbearable before requesting his prn analgesic. The nurse plans to be more attentive to Mr. Esquieres and to assess his

needs for pain management more closely. Which of the following consequences of informal planning ought to be the major concern for this nurse? A. The lack of a coordinated plan known by everyone will result in uneven pain management. B. Faulty prioritization of patient needs. C. Inability to evaluate the patients responses to the nursing care. D. Lack of a record for reimbursement purposes. Answer: The correct answer is A. If this nurse fails to incorporate this learning into the formal plan of care, other professional caregivers will not be aware of the need to monitor the patients pain needs more closely. B, C, and D may be correct answers but they should not be the major concern of the nurse. 17. When helping Mr. Esquieres turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. This is an example of: A. Initial planning B. Standardized planning C. Ongoing planning D. Discharge planning Answer: The correct answer is C. Ongoing planning is problem-oriented and has its purpose keeping the plan up to date as new actual or potential problems are identified. 18. From which of the following are outcomes derived? A. The problem statement of the nursing diagnosis B. The etiology of the problem of the nursing diagnosis C. The defining characteristics of the problem D. The evaluative statement Answer: The correct answer is A. Outcomes are derived from the problem statement of the nursing diagnosis. For each nursing diagnosis is the plan of care, at least one outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement. 19. Which of the following is an optional element in a measurable outcome? A. Subject B. Verb C. Performance Criteria D. Conditions E. Target time Answer: The correct answer is D. Conditions specify the particular circumstances in or by which the outcome is to be achieve. Not every outcome specifies condition. 20. Which of the following outcomes are correctly written?

1. At least one of the outcomes shows a direct resolution of the problem statement in the nursing diagnosis. 2. The patient values the outcome. 3. The outcomes are supportive of the total treatment plan. 4. Each outcome is brief and specific (clearly describes one observable, measurable patient behavior/ manifestation), is phrased positively, and specifies a time line. A. 2 & 4 B. 1 & 3 C. 1, 2, & 3 D. All of the above Answer: The correct answer is D.