Chapter 5 Nursing Process and Critical Thinking NCLEX Questions

Which are official categories of nursing diagnoses? (Select all that apply.)

a. Actual

b. Risk

c. Wellness

d. Syndrome

e. Potential

A, B, C, D

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

B, C, D, E

Which is an example of a medical diagnosis?

a. Pain

b. Anxiety

c. Pneumonia

d. Impaired skin integrity

c. Pneumonia

Which is an example of a nursing diagnosis?

a. Pneumonia

b. Diabetes mellitus

c. Impaired skin integrity

d. Congestive heart failure

c. Impaired skin integrity

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

a. Risk for impaired skin integrity related to physical immobilization

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.

d. The patient is pacing back and forth while chanting

.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.

d. The patient states, I hurt all over.

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%

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

From where are the risk for nursing diagnoses identified?

a. The care plan

b. The interventions

c. The assessment

d. The evaluation

c. The assessment

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

b. Ensure the patient is involved in the process

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

b. Planning

The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation?

a. Contributing to the patients recovery

b. A risk factor

c. Difficult to maintain

d. A nursing responsibility

b. A risk factor

What organized approach might the nurse use when performing a complete physical examination?

a. Maslows hierarchy of needs

b. A head-to-toe assessment

c. Subjective data collection

d. Objective data collection

b. A head-to-toe assessment

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.

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

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.

c. Patient was ambulated for 15 minutes after lunch

What is an appropriate outcome statement for a patient with a nursing diagnosis 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.

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

What are the two primary methods used to collect data?

a. Written report by patient and family

b. Review of the chart and the nurses notes

c. Interview and physical examination

d. Review of the physicians orders and the Kardex

c. Interview and physical examination

hat 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

b. Secondary

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

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

What best defines the nursing process?

a. A method to ensure that the physicians orders are implemented correctly.

b. A series of assessments that isolate a patients health problem.

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

d. A preset formula for the design of nursing care.

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