Notes

Chapter 5
1. What best defines the nursing process?
a. A method to ensure that the physician'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.
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
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
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. Anxiety5. What is classified as information provided by the family when a patient is unable to provide data during assessment?
a. Primary
b. Secondary
c. Unreliable
d. Biased
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 physician's orders and the Kardex
7. The nurse writes two nursing diagnoses: (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.
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 classifications9. What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions?
10.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.10. What is the primary purpose of nursing orders?
a. To support physician's orders
b. To provide direction for all caregivers
c. To provide broad, general statements
d. To clarify nursing principles11. What documentation reflects implementation?
11.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.
"12. Which nursing order is complete and correct?
a. "May 10: Nursing assistants will ambulate patient. A. Nurse"
b. "Day nurse will cleanse wound and change dressings every day. May 10, A.
Nurse"
c. "Nursing assistants 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."
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
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 nursing diagnosis plan. What does this data represent?
a. Symptoms
b. Data clustering
c. Signs of fluid overload
d. Urinary retention
15. What type of assessment is performed continuously throughout nurse-patient contact?
a. Complete
b. Body systems

c. Focused
d. Subjective
16. What assists the nurse in the identification of nursing diagnoses?
a. Objective data
b. Subjective data
c. Data clustering
d. Validated data
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
18. Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis?
a. Physician
b. LPN/LVN
c. RN
d. Technician
19. What is the basis for designing and selecting nursing interventions to meet patient needs?

a. Nursing diagnosis
b. Care plan
c. Physician's orders
d. Nurse's notes
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
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
21. What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking?
a. A syndrome nursing diagnosis
b. An actual nursing diagnosis
c. A "risk for" diagnosis
d. A possible nursing diagnosis
22. When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
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 nursing diagnoses is possible
24. From where are the "risk for" nursing diagnoses identified?
a. The care plan
b. The interventions
c. The assessment
d. The evaluation
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%
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.
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."
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.
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
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 chantin
32. What is an example of an appropriate nursing diagnosis?
a. Impaired skin integrity
b. Skin breakdown noted
c. Turn patient every 2 hours
d. The patient has scabies on his back
33. What is an example of an appropriate nursing diagnosis?
a. Constipation
b. Patient complains of constipation
c. Need for laxatives
d. Patient has a duodenal ulcer
34. A nurse is formulating a nursing diagnosis. What is an example of an appropriately written nursing diagnosis?
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
35. Which is an example of a nursing diagnosis?
a. Pneumonia
b. Diabetes mellitus
c. Impaired skin integrity
d. Congestive heart failure
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
37. Which is an example of a medical diagnosis?
a. Pain
b. Anxiety
c. Pneumonia
d. Impaired skin integrity
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
39. Which are official categories of nursing diagnoses? (Select all that apply.)
a. Actual
b. Risk
c. Wellness
d. Syndrome

e. Potential
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 identificatio
NANDA Internation
41. NANDA International meets to reorganize diagnosis labels and language every years.
42. The standards that name and measure patient outcomes are referred to as
43. The document that outlines a multidisciplinary plan for care interventions over a specified time frame is a .
44. A systematic method by which nurses plan and provide care for patients is known as the
45. A systemic, dynamic process by which the nurse, through interaction with the patient, significant others, and health care providers, collects and analyzes data about the patient is known as