chapter 4 Nursing Process and Critical Thinking My Nursing Test Banks

The nurse who uses the nursing process willapproach the patients disorder in a step-by-step method.
A nurse will arrive at a nursing diagnosis through the nursing process step ofassessment.
In the collaborative process of delivering care based on the nursing process, the responsibility of the LPN/LVN is tocollect data of health status.
The participants of the planning stage of the nursing process during which the health goals are defined include thehealth team, the patient, and the patients family.
When a resident in the nursing home complains of constipation, the nurse performs a digital rectal examination and finds a hard fecal mass. This is an example ofassessment.
The nurse completing morning assessments on a patient who is sitting up in bed is told by the patient, Im having trouble breathing I can’t seem to get enough air. The best nursing response is tofinish the vital signs for the assigned patients, and then notify the charge nurse.
The order in which the nursing process is approached isassessment, nursing diagnosis, planning, implementation, evaluation.
Once the nursing plan has been initiated, the nursing care plan willchange as the patient’s condition changes.
When a patient states, I can’t walk very well, the first problem-solving step would be tofind out what the problem is, such as weakness or poor balance.
A student nurse can begin to develop critical thinking skills by means oflistening attentively and focusing on the speakers words and meaning.
When a nurse prioritizes the patient care, consideration is given toconsidering situations that may result in an alteration of health.
When the nurse checks to see whether a patient has had relief 45 minutes after administering pain medication, the nurse is performing a(n)evaluation.
The activity that is implementation in nursing care ischanging the patient’s surgical dressing.
Constant nursing assessments and evaluations of the patient will most likely result inthe nursing care plan changing to reflect appropriate priorities.
The effect of using a scientific problem-solving approach in nursing care will cause decision making to beimproved nursing care outcomes.
An emergency room nurse will give first priority to the patient with the most critical need, which is the patient whocomplains of severe chest pain.
When the nurse constructs a nursing approach after careful judgment and sound reasoning, the nurse has used a system of __________.critical thinking
Critical thinking is considered to be the keystone and foundation of the development of _________.clinical judgment
The tasks of synthesizing data and linking nursing interventions with patient health problems are enhanced by the process of ________.concept mapping
Activities considered to be aspects of the implementation step of the nursing process are: (Select all that apply.)A. documentation of care given.

B. assembly of supplies.

Descriptions of the activities involved in the nursing diagnosis step of the nursing process are: (Select all that apply.)A. determination of potential health problems.

B. clustering of related assessments.

Which of the following items could be the responsibility of the LPN/LVN for a patient’s plan of care? (Select all that apply.)A. Collect data.

B. Perform nursing interventions.

C. Document nursing care.

A nurse begins rounds on a medical surgical nursing unit. Review the following patients on her assignment. Prioritize the order in which the patients should be assessed, based on their descriptions. (Separate letters with a comma and space as follows: A, B, C, D.)

A. A 22-year-old patient who is awakening from neck surgery.

B. An 82-year-old patient who is blind and needs discharge instructions.

C. A 44-year-old patient with dehydration from vomiting and diarrhea, who was admitted 3 days ago and who has an IV infusion of fluids.

D. A 35-year-old patient admitted for an injury to his left femoral artery, which required surgical repair 8 hours ago following an ice-skating accident.

A, D, C, B
Place the steps of the problem-solving approach in the appropriate order. (Separate letters with a comma and space as follows: A, B, C, D, E.)

A. Predict the likelihood of each outcome occurring.

B. Choose the alternative with the best chance of success.

C. Consider all possible alternatives as the solution to the problem.

D. Identify the problem.

E. Examine possible outcomes of each alternative.

D, C, E, A, B

chapter 5 Assessment, Nursing Diagnosis, and Planning My Nursing Test Banks

When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _______ data.subjective
The major goal of the admission interview (usually performed by the RN) is toidentify the patients major complaints.
An example of a structured format for gathering data that aids in forming a database isGordons 11 Health Patterns.
During the assessment phase of the nursing process, the nursegathers, organizes, and documents data in a logical database.
After the admission assessment is completed, on subsequent shifts or days, the nurseassesses the patient briefly in the first hour of the shift.
The nurse performing an admission interview on an elderly person shouldallow more time for a response to questions.
A nursing diagnosis consists ofdiagnostic labels formulated by the North American Nursing Diagnosis Association International (NANDA-I).
An elderly patient with a medical diagnosis of chronic lung disease has developed pneumonia. She is coughing frequently and expectorating thick, sticky secretions. She is very short of breath, even with oxygen running, and she is exhausted and says she cant breathe. Based on this information, an appropriately worded nursing diagnosis for this patient isAirway clearance, ineffective, related to lung secretions as evidenced by cough and shortness of breath.
If a patient has several nursing diagnoses, the nurse will firstprioritize the nursing problems according to Maslows hierarchy of needs.
A patient has a nursing diagnosis of Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30-pounds over the last 6 months. An appropriate short-term goal for this patient is toeat 50% of six small meals each day by the end of 1 week.
The nursing diagnoses that has the highest priority isAirway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating.
A patient with visual impairment is identified as at risk for falls related to blindness. An appropriate intervention would be toarrange furnishings in room to provide clear pathways and orient the patient to these.
The North American Nursing Diagnosis AssociationI (NANDA-I) list is revised and updated every2 years.
A nursing care plan consists ofnursing orders for individualized interventions to assist the patient to meet expected outcomes.
In an acute care facility, a nursing care plan is usually reviewed and updatedevery 24 hours.
The nurse takes into consideration that the difference between a sign and a symptom is that a sign iscan be verified by examination.
The nurse clarifies that nursing orders are also calledinterventions.
The nurse designs the goals for patients in long-term facilities to belong-term.
Standardized Nursing Care Plans canhave items altered or deleted.
A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient isAirway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung.
Conclusions that have been made based on observed data are __________.inferences
The nurse understands that an expected outcome should be: (Select all that apply.)realistic.


within a defined time.

included after patient collaboration.

A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurologic impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.)Assist with range-of-motion exercises every 4 hours and as needed.

Instruct patient to call for assistance when needing to get out of bed.

Teach about exercises that will strengthen muscles while lying in bed.

Ambulate with physical therapy assistance at least three times a day.

Appropriate nursing roles in the initial assessment would include: (Select all that apply.)LPN obtains the vital signs of a new patient.

RN performs a complete physical assessment.

RN reviews the patients chart for past medical/surgical history.

LVN contributes ongoing assessments.

Aside from the information obtained from the patient (primary source) in the admission interview, the nurse will also access: (Select all that apply.)the patients family.

the admission note.

the physicians history and physical.

an observation of the patient for non-verbal clues.

A nursing diagnosis identifies: (Select all that apply.)patients response to illness.

related signs and symptoms.

causative factors.

potential risk for health problems.

The statements that are correctly stated as expected outcomes are: (Select all that apply.)Patient will be able to ambulate using a walker independently within 3 days.

Patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours.

The nurse should make a point when closing the initial interview to: (Select all that apply.)summarize the problems discussed.

thank the patient for his or her time.

The seven domains of the Nursing Interventions Classification (NIC) taxonomy include: (Select all that apply.)community.

health system.



The purpose of the Nursing Outcomes Classification (NOC) is to: (Select all that apply.)validate classification by field test.

identify labels.

provide language labels for desired outcomes.

identify patient outcomes and indicators.