Fundamentals Of Nursing Process Quiz

a) During the assessment step of the Nursing Process data are collected from different sources using various methods such as physical examination, interviewing, and observation. As data are collected, they are clustered into groups that have a relationship - CORRECT ANSWER

b) Evaluation occurs during the Nursing Process when the nurse assesses a patient's response to an intervention, not when collecting baseline data about a patient's status.

c) Taking a patient's vital signs is not an example of diagnosing. During the Diagnosis step of the Nursing Process, data are critically analyzed, interpreted, and significance determined; inferences are made and validated ; cues and clusters are compared with the defining characteristics of nursing diagnoses; contributing factors are identified; and nursing diagnoses are identified and organized in order of priority.

d) This scenario is not an example of the implementation step of the Nursing Process. Implementation occurs when the plan of care is put into action and nursing care is actually delivered.

a) A yellow color of the skin, whites of the eyes, and mucous membranes (jaundice) because of deposition of bile pigments from excess bilirubin in the blood is objective, not subjective information. Objective data are measurable and checkable.

b)This is subjective information because it is the patient's perception and can be verified only be the patient. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm - CORRECT ANSWER

c) Excessive sweating (Diaphoresis) is objective, not subjective. It is measurable and checkable.

d) Abnormally low systolic and diastolic blood pressure levels (hypotension) can be measured and verified and are therefore objective data.

a) This is an objective statement indicating something that is checkable and measurable. Objective data can be verified.

b) A patient's perception of pain is subjective. Pain is always subjective. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm. - CORRECT ANSWER

c) This is objective. It is checkable and can be verified

d) This is objective since food consumption can be measured and verified.

a) This is not a nursing diagnosis. Fatigue, activity intolerance, disturbed sleep pattern and sleep deprivation are just a few examples of nursing diagnoses associated with a patient who is looking tired.

b) This is not Evaluation. Evaluation occurs when the nurse assesses a patient's response to an intervention. This patient is newly admitted and nursing care has not yet been planned or or implemented

c) This statement is an example of the use of the interviewing skill of clarification to obtain baseline information about the patient during the Assessment step of the Nursing Process - CORRECT ANSWER

d) This is not implementation. Implementation occurs when the nurse provides nursing care identified in the patient's nursing plan of care.

a) Not an example of Planning step of the Nursing Process. During the planning step, the nurse identifies and plans the nursing interventions that seem most likely to be effective.

b) Not an example of the Diagnosis step of the Nursing Process. In the diagnosis step, data are analyzed and interpreted; significance of data are determined: interferences are made and validated; cues and clusters of cues are compared with defining characteristics of diagnosis; contributing factors are identified; and nursing diagnosis are identified and organized in order of priority.

c) Not an example of Evaluation. Evaluation occurs when actual outcomes are compared with expected outcomes that reflect goal achievement.

d) This is an example of the Implementation Step of the Nursing Process. During this step, nursing care that is planned is delivered. CORRECT ANSWER

a) Although this is true, it is not the primary purpose. When a five-step Nursing Process is followed, identifying goals and outcomes occur during the Planning, not Assessment, step of the process.

b) When a five-step Nursing Process is followed identifying goals and outcomes occur during the Planning, not Assessment step of the process.

c) The primary purpose of the Assessment step of the Nursing Process is to collect data from various sources using a variety of approaches. After data are collected, they are clustered into meaningful categories in preparation for the analysis and interpretation that takes place during the Diagnosis step of the Nursing Process. - CORRECT ANSWER

d) Identifying and validating the medical diagnosis are not within a Registered Nurse's legal scope of nursing practice.

a) Observation is the deliberate use of all the senses, and involves more than just inspection and examination. It includes surveying, looking, scanning, scrutinizing, and appraising. Although the nurse makes inferences based on data collected by observation, this is not as effective as another data collection method to identify subjective data associated with a patient's anxiety.

b) Inspection involves the act of making observations of physical features and behavior. Although the nurse observes behavior and makes inferences based on their perceived meaning, another data collection method is more effective in identifying subjective data associated with a patient's anxiety.

c) Auscultation is listening for sounds within the body. This collects objective, not subjective data which are measurable.
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d)Interviewing a patient is the most effective data collection method when collecting subjective data associated with a patient's anxiety. The patient is the primary source for subjective data about beliefs, values, feelings, perceptions and fears and concerns - CORRECT ANSWER

a) The Nursing Process is a dynamic five-step problem-solving process (Assessment, Diagnosis, Planning, Implementation, and Evaluation) designed to diagnose and treat human responses to health problems. It is constantly changing in response to the changing needs of the patient - CORRECT ANSWER b) The Nursing Process focuses on the needs of the patient and not on the role of the nurse. c) Moving from the simple to the complex is a principle of teaching, not the Nursing Process. The Nursing Process is a complex interactive five step problem-solving process designed to meet a patient's needs. It requires an understanding of systems and information processing theory, and the critical thinking, problem-solving, decision-making and diagnostic reasoning processes. d) The Nursing Process is concerned with a person's human responses to actual or potential health problems, not the patient's medical problem.

a) A patient's perception of pain is always subjective. Pain is always subjective. Only a patient can confirm this.

b) An irregular radial pulse is objective not subjective. Objective data are measurable and checkable. - CORRECT ANSWER

c) A patient's complaint of shortness of breath is subjective and not objective. When the nurse counts respiration, then it becomes objective

d) Dizziness is also subjective. Only a patient can confirm and measure this.

a) The words 'identify' and 'recognize' have the same definition. They both mean the same as that which is known. The word 'plan' does not fit the analogy because the definitions of the 'plan' and 'do' are different. The word 'plan' means a method of proceeding. The word 'do' means to carry into effect or to accomplish.

b) The words 'identify' and 'recognize' have the same definition. They both mean the same as that which is known. The word 'evaluate' does not fit the analogy because the definitions of 'evaluate' and 'do' are different. The word 'evaluate' means to determine the worth of something, whereas the word 'do' means to carry into effect or to accomplish.

c) The words 'identify' and 'recognize' have the same definition. They both mean the same as that which is known. The word diagnose does not fit the analogy because the definitions of diagnose and do are different. The word "diagnose" means to identify the patient's human response to an actual or potential health problem. The word 'do' means to carry into effect or to accomplish.

d) This is the correct analogy. The words 'identify' and 'recognize' have the same definition. They both mean the same as that which is known. The words 'do' and 'implement' both have the same definition. They both mean to carry out some action - CORRECT ANSWER

a) Although functioning as a teacher is an important role of the nurse, it is a limited role compared to another option. As a teacher the nurse helps the patient gain new knowledge about health and health care to maintain or restore health.

b) When the nurse supports, protects, and defends a patient from a holistic perspective, the nurse functions as an advocate. Advocacy includes exploring, informing, mediating and affirming in all areas to help a patient navigate the health care system, maintain autonomy, and achieve the best possible health outcomes - CORRECT ANSWER

c) Although functioning as a counselor is an important role of the nurse, it is a limited role compared to another option. As counselor, the nurse helps the patient improve interpersonal relationships, recognize and deal with stressful psychosocial problems and promote achievement of self-actualization.

d) The word surrogate is not the word that best describes this scenario. The nurse is placed in the surrogate role when a patient projects into the nurse the image of another and then responds to the nurse with the feelings for the image.

a) Low blood pressure is an adaptation that can me measured objectively and is NOT AN INFERENCE.

b) When making a statement "the patient is withdrawn", the Nurse is making an inference. This is based on a pattern of behavior such as lack of eye contact, somnolence, apathy, and verbalization of defeat - CORRECT ANSWER

c) A yellow color to the skin, mucous membranes and whites of the yes as a result of deposition of bile pigment resulting from excess bilirubin in the blood is called jaundice. The presence of bilirubin can be measured objectively by a blood test (serum bilirubin) and is not an inference.

d) A patient experiencing urine output of less than 500 ml per 24 hours (oliguria) is measurable and therefore is not an inference.

a) Data must be collected and significance determined before a nursing diagnosis can be made

b) Although completing a nursing admission assessment includes an assessment of the skin, it is only one component of the assessment

c) Although completing a nursing admission assessment helps to initiate the nurse-patient relationship, it is not the primary purpose of completing a nursing admission statement

d) This is the primary purpose of a nursing admission assessment. Data must be collected, analyzed to determine significance, and grouped in meaningful clusters before a nursing diagnosis can be made - CORRECT ANSWER

a) To evaluate the effectiveness of a nursing action, the nurse needs to compare the actual patient outcome with the expected patient outcome. The expected outcomes are the measurable data that reflect goal achievement, and the actual outcomes are what really happened - CORRECT ANSWER

b) The problem is associated with the first half (problem statement) of the Nursing Diagnosis, not the Evaluation step of the Nursing Process

c) Etiology is a term used to identify the factors that relate to the problem statement of the Nursing process

d) Implementation is a step separate from Evaluation in the Nursing Process. Nursing care must be implemented before it can be evaluated.

a) This occurs during the planning, not diagnosis step of the Nursing Process

b) Potential risk factors are identified during the diagnosis step of the Nursing Process. Risk diagnosis are designed to address situations where patients have a particular vulnerability to health problems - CORRECT ANSWER

c) This occurs during PLANNING and not diagnosis step of the nursing process

d) This occurs during the Evaluation, not diagnosis step of the Nursing process.

a) DIAGNOSIS does not fit because PLANNING in the Nursing Process happens after, not before, the Nursing Diagnosis.

b) The word IMPLEMENT appropriately completes the analogy. In the first half of the analogy, the PRESENT happens before the FUTURE. In the second part of the analogy PLANNING happens immediately before IMPLEMENTATION in the Nursing Process - CORRECT ANSWER

c) In the first half of the analogy, the PRESENT happens before the FUTURE. . In the second part of the analogy, EVALUATION does not fit well as another option. Although PLANNING happens before EVALUATION, Evaluation IS NOT THE IMMEDIATE STEP after planning

d) In the first half of the analogy, the PRESENT happens before the FUTURE. . In the second part of the analogy, ASSESSMENT does not fit because PLANNING in the Nursing Process happens after, not before the ASSESSMENT

a) This is subjective information because it is the patient's perception and can be verified only by the patient. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm - CORRECT ANSWER

b) This is neither subjective nor objective. It is a statement indicating an understanding of how to seek home care services after discharge

c) Neither subjective nor objective. It is a question indicating that the patient wants more information about how to control pain when at home.

d) This is neither subjective nor objective. It is a patient statement indicating an understanding of who will provide assistance with care once the patient goes home.

a) During the Implementation step of the Nursing Process, outcomes are not determined but rather nursing care that has been planned is delivered.

b) Evaluation occurs when actual outcomes are compared with expected outcomes that reflect goal achievement. If the goal is achieved, the patients needs are met. - CORRECT ANSWER

c) During the Diagnosis step of the Nursing process, expected outcomes are determined, but their achievement is measured in another step of the Nursing Process

a) Inappropriate because the word LOWER is not specific, measurable or objective

b) This is not a goal. This is an action the nurse plans to implement to help a patient achieve a goal

c) This is not a goal. This is an action the nurse plans to implement to help a patient achieve a goal.

d) This is a well-written goal. Goals must be patient-centered, specific, measurable, realistic, and have a time frame in which the expected outcome is to be achieved. The words SUFFICIENT and DEHYDRATION are based on generally accepted criteria against which to measure the patient's actual outcome. The word MAINTAIN connotes continuously, which is a time frame. - CORRECT ANSWER

a) This is not a goal. This is an action the nurse plans to implement to help a patient achieve a goal.

b) This goal is inappropriate because the word FEWER is not specific, measurable or objective

c) This is not a goal. This is an action the nurse plans to implement to help a patient achieve a goal.

d) This is a correctly worded GOAL. Goals must be patient-centered, measurable, realistic, and include the time frame in which the expected goal is to be achieved. The word INDEPENDENTLY indicates that no help is needed. and the word SAFELY indicates that no injury will occur. - CORRECT ANSWER

a) The word DATA (evidence or information) is not associated with the term SCIENTIFIC PRINCIPLES (established rules of action).

b) The word PROBLEM (difficulty or crisis) is not associated with the term SCIENTIFIC PRINCIPLES (established rules of action)

c) The word RATIONALE (justification based on reasoning) is closely associated with the term SCIENTIFIC PRINCIPLES (established rules of action) SCIENTIFIC PRINCIPLES are based on RATIONALES- CORRECT ANSWER

d) The word EVALUATION (determining the value or worth of something) is not associated with the term SCIENTIFIC PRINCIPLES (established rules of action)

a) This does not occur during the implementation step of the Nursing Process. During the Implementation step the nurse puts the plan of care into action. Nursing interventions include actions that are dependent (requiring a physician's order), independent (autonomous actions within the nurse's scope of practice),, and interdependent (interventions that require a physician's order but that permits the nurse to use clinical judgment in their implementation).

b) This does not occur during the Assessment step of the Nursing Process. During the Assessment step the Nurses use various skills such as observation, interviewing and physical examination to collect data from various sources.

c) This does not occur during the Nursing Diagnosis step of the Nursing Process. A nursing Diagnosis is made when the nurse identifies the patient's human response to actual or potential health problems.

d) Nursing actions designed to help a patient achieve a goal occur during the Planning step of the Nursing Process. - CORRECT ANSWER

a) In this step, data are critically analyzed and interpreted; significance of data is determined; inferences are made and validated; cues and clusters of cues are compared with the defining characteristics of nursing diagnoses; contributing factors are identified; and nursing diagnoses are identified and organized in order of priority - CORRECT ANSWER

b) Not a step in the Nursing Process. Clustering occurs during the assessment step and is a precursor to critical analysis which occurs in the next step of the Nursing Process

c) Not a step in the Nursing Process. During Assessment, data is collected from different sources using various methods and then it is generally clustered into groups that have a relationship.

d) In this step of the Nursing Process, data are collected from different sources using various methods. As data are collected they are generally clustered into groups that have a relationship. Although clustering requires interpretation of data, critical analysis of data occurs in the next step of the Nursing Process.

a) The definitions of the words OBSERVE and ASSESS are similar. OBSERVE means to examine something scientifically, and ASSESS means to determine the significance of something. The word PLAN does not fit the analogy because the definitions of the words plan and determine are not similar. DETERMINE means to reach a decision. PLAN means to carry into effect or to accomplish. b) The definitions of the words OBSERVE and ASSESS are similar. OBSERVE means to examine something scientifically, and ASSESS means to determine the significance of something. the word ANALYZE does not fit the analogy because analyze is not a step in the Nursing Process. The steps in the Nursing Process are Assessment, Diagnosis, Planning, Implementation and Evaluation. c) The definitions of the words OBSERVE and ASSESS are similar. OBSERVE means to examine something scientifically, and ASSESS means to determine the significance of something. The word DIAGNOSE appropriately completes the analogy because the definitions of determine and diagnose are similar. DETERMINE means to reach a decision about something and DIAGNOSE means to make a decision based on the assessment and analysis of a human response. - CORRECT ANSWER d) The definitions of the words OBSERVE and ASSESS are similar. OBSERVE means to examine something scientifically, and ASSESS means to determine the significance of something, The word IMPLEMENT does not fit the analogy because the definitions of determine and implement are not similar. DETERMINE means to reach a decision about something and IMPLEMENT means to carry out some action.

a) This is an action the nurse plans to implement; it does not identify a patient goal or expected outcome b) This goal is inappropriate because the word 'good' is not specific, measurable or objective c) This is a well-written goal. Goals must be patient-centered, measurable, realistic and indicate the time frame in which the expected outcome is to be accomplished. The word correctly implies that critical elements are used as standards to measure the patient's actions when self-administering medication. - CORRECT ANSWER d) This is an action the nurse plan to implement; it does not identify a patient goal or expected outcome

a) Defining characteristics do not contribute to the problem statement but support or indicate the presence of the Nursing Diagnosis. Defining characteristics are the major and minor clinical cues that support the presence of a Nursing Diagnosis. b) Outcome criteria are not part of the nursing diagnosis. Outcome criteria (goals) are part of the planning step of the Nursing Process. c) The ETIOLOGY (also known as related or contributing factors) are the conditions, situations, or circumstances that add to the development of the human response identified in the problem statement of the nursing diagnosis. The ETIOLOGY precipitates the problem just as a pebble dropped in a pond causes ripples on the surface of water - CORRECT ANSWER d) Goals are not part of the nursing diagnosis. Goals are the expected outcomes or what is hoped that the patient will achieve in response to nursing intervention.

a) The Defining Characteristics are the major and minor cues that form a cluster that support or validate the presence of a Nursing Diagnosis. At least one major defining characteristic must be present for a nursing diagnosis to be considered appropriate for the patient. - CORRECT ANSWER b) Planned interventions do not support Nursing Diagnosis. They are the Nursing actions designed to help resolve the related to factors and achieve expected patient outcomes that reflect goal achievement. c) The diagnostic statement cannot support the Nursing Diagnosis because it is the first part of the Nursing Diagnosis. A Nursing Diagnosis is made up of two parts, the diagnostic statement (also known as the problem statement) and the related to factors (also known as factors that contribute to the problem or the etiology). d) Related risk factors cannot support the Nursing diagnosis because they are the second part of the nursing diagnosis. A Nursing Diagnosis is made up of two parts, the diagnostic statement (also known as the problem statement) and the related to factors (also known as factors that contribute to the problem or the etiology).

a) Not an example of implementation. During implementation, planned nursing care is delivered.

b) Not an example of assessment. Although data may be gathered during assessment step, manipulation of data is conducted in a different step of the nursing process.

c) Not an example of Evaluation which occurs when actual outcomes are compated with expectd outcomes, which reflect attainment of the goal

d) During the DIAGNOSIS step of the nursing process, data are critically analyzed and interpreted; significance of data is determined; inferences are made and validated; cues and clusters of cues are compared with the defining characteristics of nursing diagnoses; contributing factors are identified; and nursing diagnosis are identified and organized in order of priority - CORRECT ANSWER

a) If a thorough assessment is completed initially, a reassessment should not be necessary

b) To establish which of two nursing diagnoses is most appropriate is not dependent upon identifying the factors that contributed to (also known as related to or etiology of) the nursing problem. These factors are identified after the problem statement is identified.

c) To establish which of two nursing diagnoses is more appropriate is not dependent upon analyzing the secondary to factors. Secondary to factors are generally medical conditions that precipitate the related to factors. The secondary to factors are identified after the related to factors of the problem are identified

d) The first thing the nurse should do to differentiate between two closely associated nursing diagnoses is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered - CORRECT ANSWER

a) Loss of appetite (anorexia) is an example of subjective, not objective data. Subjective data are those adaptations, feelings, beliefs, preferences and information that only the patient can confirm.

b) Feeling warm is an example of subjective, not objective data. Subjective data are those adaptations, feelings, beliefs, preferences and information that only the patient can confirm.

c) The amount of food eaten by a patient can be objectively verified. The nurse measures and documents the percentage of a meal ingested by a patient to quantify the amount of food consumed - CORRECT ANSWER

d) Having the urge to void is an example of subjective and not objective data.

a) Related factors contributing to the problem statement of the Nursing Diagnosis and directly impact on the Planning step of the Nursing Process. Nursing interventions are selected to minimize or relieve the effects of the related factor. If nursing interventions are appropriate and effective, the human response identified in the problem statement part of the Nursing Diagnosis will be resolved. - CORRECT ANSWER

b) The planning step of the Nursing Process includes setting a goal, identifying the outcomes that will reflect goal achievement, and planning nursing interventions. Although the working of the goal is directly influenced by the diagnostic label (problem statement of the Nursing Diagnosis), the selection of the nursing intervention is not.

c) The medical diagnosis does not influence the planning step of the Nursing Process. The nurse is concerned with human responses to actual or potential health problems, not the medical diagnosis.

d) Secondary factors generally have only a minor influence on the Planning step of the Nursing Process.

a) Physician's history and physical contain history of the patient, a physical and the medical problems on the day of admission to the hospital. The admission medical diagnosis may be different after diagnostic tests are completed.

b) Although the patient's medical diagnosis might be documented on the patient's Social Service Record, it is not the major source for this information.

c) This is the best source for identifying the patient's admitting medical diagnosis, but it will not contain the current medical diagnosis if the diagnosis changed after completion of diagnostic tests.

d) Generally the Progress notes contain documentation by all members of the health team. After a patient is admitted and diagnostic tests completed, the patient's medical diagnosis may change. The on-going changes and current status of the patient are documented in the Progress Notes - CORRECT ANSWER

a) Establishing outcomes is part of the Planning, not Evaluation step of the Nursing Process

b) Determining priorities is part of the Diagnosis, not Evaluation, step of the Nursing Process. Priority setting is a decision-making process that ranks a patient's nursing diagnoses in order of importance.

c) Corrective action takes place in the evaluation step of the nursing process. If during evaluation it is determined that the goal was not met, the reasons for failure have to be identified and the plan modified - CORRECT ANSWER

d) Setting time frames for goals to be achieved is part of the Planning, not Evaluation, step of the Nursing Process.

a) Goals are designed after a Nursing Diagnosis is identified, not after data are collected.

b) Once data are collected, the nurse must first organize and cluster the data to determine significance and make inferences. After all this is accomplished, then the nurse can formulate a Nursing Diagnosis.

c) Nursing care is planned after Nursing Diagnoses and goals are identified, not after data are collected

d) After data are collected, they are clustered to determine their significance - CORRECT ANSWER

a) This is not a Nursing Diagnosis. Fatigue and activity intolerance are two nursing diagnosis associated with this scenario. b) This statement is an attempt to obtain information about a patient's response to an intervention, ambulation. Assessing a patient's tolerance to ambulation is conducted in the Evaluation Step of the Nursing process - CORRECT ANSWER c) A step other than Assessment is best reflected in this scenario. Assessment occurs in the first step of the Nursing Process before Diagnosis, Planning, Implementation and Evaluation. d) When the nurse assists a patient with ambulation, the nurse is implementing, not evaluating, the nursing plan of care.