Chapter 5 - nursing process and critical thinking

1. What best defines the nursing process?

c. A framework for the organization of individualized 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

3. What subjective data does the nurse record following a head-to-toe examination?

b. Prolonged nausea

4. What objective data should the nurse include after a patient assessment?

c. Flatulence

5. What is classified as information provided by the family when a patient is unable to provide data during assessment?

b. Secondary

6. What are the two primary methods used to collect data?

c. Interview and physical examination

7. The nurse writes two patient problems: (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?

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?

c. Maslow's hierarchy of needs

9. What is an appropriate outcome statement for a patient with a patient problem of ineffective airway clearance related to thick secretions?

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

10. What is the primary purpose of nursing interventions?

b. To provide direction for all caregivers

11. What documentation reflects implementation?

c. "Patient was ambulated for 15 minutes after lunch."

12. Which nursing intervention is complete and correct?

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

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?

b. Variance

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 patient problem plan. What does this data represent?

b. Data clustering

15. What type of assessment is performed continuously throughout nurse-patient contact?

c. Focused

16. What assists the nurse in the identification of patient problems?

c. Data clustering

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

b. A head-to-toe assessment

18. Who is the person responsible for analyzing and interpreting data to arrive at a patient problem?

c. RN

19. What is the basis for designing and selecting nursing interventions to meet patient needs?

a. Patient problem

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

b. A risk factor

21. What is a patient problem considered when a problem is suspected but data to support it are lacking?

d. A possible patient problem

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?

b. Planning

23. What is an important consideration when developing the care plan?

b. Ensure the patient is involved in the process.

24. From where are the "risk for" patient problems identified?

c. The assessment

25. What expected outcome exemplifies accepted criteria?

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

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.

27. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

d. The patient states, "I hurt all over."

28. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

d. The patient complains of generalized discomfort

29. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

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.

31. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

d. The patient is pacing back and forth while chanting.

32. What is an example of an appropriate Patient problem?

a. Impaired skin integrity

33. What is an example of an appropriate patient problem?

a. Constipation

34. A nurse is formulating a patient problem. What is an example of an appropriately written patient problem?

a. Risk for impaired skin integrity related to physical immobilization

35. Which is an example of a patient problem?

c. Impaired skin integrity

36. Which is an example of a medical diagnosis?

b. Diabetes mellitus

37. Which is an example of a medical diagnosis?

c. Pneumonia

1. Which are acceptable secondary sources for data? (Select all that apply.)

b. Family members

c. Other health professionals

d. Diagnostic reports

e. Textbooks

2. Which are official categories of patient problems? (Select all that apply.)

a. Actual

b. Risk

c. Wellness

d. Syndrome

3. Which are considered phases of the nursing process? (Select all that apply.)

a. Diagnosis

c. Assessmnet,

d.Evaluation

e.Implementation

f. Outcome identification

Definition of these nursing diagnoses:

Actual: problem that has occurred

Risk: potential problem

Syndrome: cluster of nursing diagnosis

Health promotion: readiness to enhance health