introduction to the nursing process

Question 1

which nursing skill is essential to utilize throughout the nursing process?

• analysis
• observation
• critical thinking
• time management

Answer 1

critical thinking

Question 2

place the steps of the nursing process in the order in which each should occur

• analysis
• implementation
• evaluation
• assessment
• planning

Answer 2

• assessment
• analysis
• planning
• implementation
• evaluation

Question 3

match the nursing process characteristic to its description
- organized
- analytical
- collaborative
- outcome-oriented

the nursing process incorporates the interprofessional team

Answer 3

collaborative

Question 4

match the nursing process characteristic to its description
- organized
- analytical
- collaborative
- outcome-oriented

nurses evaluate patient results to determine effectiveness

Answer 4

outcome-oriented

Question 5

match the nursing process characteristic to its description
- organized
- analytical
- collaborative
- outcome-oriented

nurses use critical thinking for each step of the nursing process

Answer 5

analytical

Question 6

match the nursing process characteristic to its description
- organized
- analytical
- collaborative
- outcome-oriented

the nursing process helps ensure the patient care is well planned

Answer 6

organized

Question 7

which component determines whether an assessment is primary or secondary?

• source of data
• types of data
• categories of data
• objectivity of the data

Answer 7

source of data

Question 8

match the category of data with its description

• primary
• secondary
• objective
• subjective

obtained directly from patient

Answer 8

primary

Question 9

match the category of data with its description

• primary
• secondary
• objective
• subjective

blood pressure reading and weight

Answer 9

objective

Question 10

match the category of data with its description

• primary
• secondary
• objective
• subjective

direct quotes describing patient feelings

Answer 10

subjective

Question 11

match the category of data with its description

• primary
• secondary
• objective
• subjective

obtained from other health care professionals or medical records

Answer 11

secondary

Question 12

which examples reflect subjective data?

• signs
• feelings
• symptoms
• perceptions
• laboratory findings
• health history

Answer 12

• feelings
• symptoms
• perceptions
• health history

Question 13

which nursing concept is defined as an actual or potential problem or response to a problem?

• plan
• outcome
• diagnosis
• assessment

Answer 13

diagnosis

Question 14

which aspects do nurses make judgments about when determining initial nursing diagnoses?

• vulnerabilities
• patient problems
• health promotion
• risk for problems
• evaluative measures

Answer 14

• vulnerabilities
• patient problems
• health promotion
• risk for problems

Question 15

which action reflects a primary task in the analysis step of the nursing process?

• initiating nursing actions
• forming diagnostic conclusions
• identifying realistic patient goals
• examining the effectiveness of interventions

Answer 15

forming diagnostic conclusions

Question 16

which term describes how the nursing process changes over time in response to patients individual needs?

• dynamic
• analytical
• organized
• adaptable

Answer 16

dynamic

Question 17

which statement defines collaborative interventions?

• involve independent nursing interventions
• establish the effectiveness of nursing actions
• require a prescription from the health care provider
• involve the expertise of health care team members

Answer 17

involve the expertise of health care team members

Question 18

match the type of nursing intervention to the example

• interdependent
• independent
• dependent

patient positioning

Answer 18

independent

Question 19

match the type of nursing intervention to the example

• interdependent
• independent
• dependent

foley catheter insertion

Answer 19

dependent

Question 20

match the type of nursing intervention to the example

• interdependent
• independent
• dependent

respiratory therapy consult

Answer 20

interdependent

Question 21

which function describes the primary purpose for documenting nursing interventions?

• implement policy
• prove task completion
• facilitate communication
• ensure proper record-keeping

Answer 21

facilitate communication

Question 22

which interventions reflect indirect nursing care?

• giving an injection
• helping a patient ambulate in the hall
• documenting medications administered
• collaborating to schedule occupational therapy
• working with a social worker to set up home care

Answer 22

• documenting medications administered
• collaborating to schedule occupational therapy
• working with a social worker to set up home care

Question 23

during the implementation step of the nursing process, a nurse reviews and revises a patients plan of care. place the steps of review and revision in the order in which each should occur

• review and revise the existing plan of care
• implement nursing interventions
• reassess the patient
• organize resources and care delivery
• anticipate and prevent complications

Answer 23

• reassess the patient
• review and revise the existing plan of care
• organize resources and care delivery
• anticipate and prevent complications
• implement nursing interventions

Question 24

which aspect would the nurse consider as a component of the evaluation step of the nursing process?

• the patient being discharged from the hospital
• the patients achievement of short and long term goals
• the nurses completion of interventions in the plan of care
• the nurses view on the patients desire to perform interventions

Answer 24

the patients achievement of short and long term goals

Question 25

which critical thinking functions must the nurse perform to effectively evaluate patient goals during the final step of the nursing process? - recognizing errors - gathering patient cues - documenting patient progress - comparing achieved effect with goals - examining results according to clinical findings

Answer 25

- recognizing errors - comparing achieved effect with goals - examining results according to clinical findings

Question 26

which questions would the nurse ask when revising the plan of care because of unmet patient goals? - were the original goals realistic? - what unanticipated events occurred? - were the original goals collaborative? - what steps in the process can be handled differently? - what barriers did the patient encounter that prevented goal attainment?

Answer 26

- were the original goals realistic? - what unanticipated events occurred? - what steps in the process can be handled differently? - what barriers did the patient encounter that prevented goal attainment?

Question 27

Which characteristics of the nursing process allow the nurse to effectively apply critical thinking to patient care? - It is organized. - It is outcome-oriented. - It necessitates observation skills. - It allows nurses to apply knowledge. - It requires nurses to think analytically. - It incorporates an interprofessional team.

Answer 27

- It is organized. - It is outcome-oriented. - It allows nurses to apply knowledge. - It requires nurses to think analytically. - It incorporates an interprofessional team.

Question 28

Which organization defines standards of nursing practice and states that the nursing process forms the foundation for clinical decision making? - American Academy of Nursing - National Student Nurses Association - National League for Nursing - American Nurses Association

Answer 28

American Nurses Association

Question 29

Which questions are critical for the nurse to ask during each step in the nursing process? - Were patient goals met? - Can interventions be universally applied? - Is collected data thorough and accurate? - Could interventions affect the patient negatively? - Are all underlying factors addressed in the plan of care?

Answer 29

- Can interventions be universally applied? - Is collected data thorough and accurate? - Could interventions affect the patient negatively? - Are all underlying factors addressed in the plan of care?

Question 30

Which step of the nursing process does the nurse use when obtaining the following patient information: blood pressure of 180/75, pulse of 90, and a complaint of chest pain? - analysis - evaluation - assessment - implementation

Answer 30

assessment

Question 31

Which type of data do the patient's family members, friends, or other nurses provide? - primary - objective - secondary - comprehensive

Answer 31

secondary

Question 32

Which type of patient assessment takes into account all factors, such as the patient's physical, psychological, emotional, environmental, cultural, and spiritual health? - general - holistic - focused - universal

Answer 32

holistic

Question 33

Which nursing action occurs during the analysis step of the nursing process? - Initiating nursing interventions and treatments - identifying realistic goals that are patient-focused - Clustering patient data to identify patient problems - Gathering patient data through a variety of sources

Answer 33

Clustering patient data to identify patient problems

Question 34

Which phrase describes the primary purpose of nursing analysis and diagnosis? - resolves patient confusion - communicates patient problems - articulates the nursing scope of practice - describes the medical context of the patient problem

Answer 34

communicates patient problems

Question 35

Which phrases describe the role of the International Classification for Nursing Practice (ICNP) in the nursing process? - provides a standardized nursing language - outlines categories for patient information - categorizes priorities based on importance - identifies common labels for nursing diagnoses - provides point-of-care documentation for clinical activity

Answer 35

- provides a standardized nursing language - identifies common labels for nursing diagnoses - provides point-of-care documentation for clinical activity

Question 36

During which step of the nursing process would the nurse prioritize nursing diagnoses? - planning - analysis - evaluation - assessment

Answer 36

planning

Question 37

During which step of the nursing process would the nurse establish long-term goals with the patient? - planning - analysis - evaluation - implementation

Answer 37

planning

Question 38

Which part of the nursing process involves the nurse setting short-term goals for the patient? - planning - diagnosis - evaluation - assessment

Answer 38

planning

Question 39

Which step of the nursing process involves carrying out nursing actions designed to meet a patient’s unique needs? - planning - analysis - evaluation - implementation

Answer 39

implementation

Question 40

Which intervention reflects direct nursing care? - Working with a social worker to set up home care - Documenting nursing interventions - Asking the health care provider to prescribe a special diet - Giving an injection

Answer 40

Giving an injection

Question 41

Which statements reflect the nurse’s role during the implementation step of the nursing process? - Be accountable for safe practice. - Consult with the health care provider. - Collaborate with support services. - Perform the steps of intervention accurately. - Understand why an intervention is planned.

Answer 41

- Be accountable for safe practice. - Perform the steps of intervention accurately. - Understand why an intervention is planned.

Question 42

Which step of the nursing process considers the effectiveness of nursing care? - planning - analysis - evaluation - implementation

Answer 42

evaluation

Question 43

Which step of the nursing process includes a decision point on whether to discontinue, continue, or revise the plan of care? - planning - evaluation - assessment - implementation

Answer 43

evaluation

Question 44

Which questions would the nurse ask to evaluate the effectiveness of nursing interventions? - Should the plan of care be discontinued? - Which nursing diagnosis covers this cluster of signs and symptoms? - Have new assessment data been identified that should be considered? - Did the patient meet the goals established during the implementation phase? - Does the plan of care need to be modified in response to patient changes?

Answer 44

- Should the plan of care be discontinued? - Have new assessment data been identified that should be considered? - Does the plan of care need to be modified in response to patient changes?