Nursing Process

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care?

• Proposes hypotheses

• Generates desired outcomes

• Review results of laboratory tests

• Documents care

Which of the following is the purpose of assessing?

• Establish a database of client responses to his or her health status

• Identify client strengths and problems

• Develop an individualized plan of care

• Implement care, prevent illness, and promote wellness

The nurse is conducting the diagnosing phase (nursing diagnosis) of the nursing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement?

• Assess the client’s needs

• Delineate the client’s problems and strengths

• Determine which interventions are most likely to succeed.

• Estimate the cost of several different approaches

Which of the following nursing diagnoses contains the proper components?

• Risk for Caregiver Role Strain related to unpredictable illness course

• Risk for Falls related to tendency to collapse when having difficulty breathing

• Impaired Communication related to stroke

• Sleep Deprivation secondary to fatigue and a noisy environment

Which of the following is likely to occur if a goal statement is poorly written?

• There is no standard against which to compare outcomes.

• The nursing diagnoses cannot be prioritized.

• Only dependent nursing interventions can be used

• It is difficult to determine which nursing interventions can be delegated.

Which of the following principles does the nurse use in selecting interventions for the care plan?

• Actions should address the etiology of the nursing diagnosis

• Always select independent interventions when possible

• There is one best intervention for each goal/outcome.

• Interventions should be “doing,” not just “monitoring.”

When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first?

• Carrying out nursing interventions

• Determining the need for assistance

• Reassessing the client

• Documenting interventions

Which of the following is true regarding the relationship of implementing to the other phases of the nursing process?

• The findings from the assessing phase are reconfirmed in the implementing phase.

• After implementing, the nurse moves to the diagnosing phase

• The nurse’s need for involvement of other health care team members in implementing occurs during the planning phase

• Once all interventions have been completed, evaluating can begin.

The primary purpose of the evaluation phase of the care planning process is to determine whether

• Desired outcomes have been met

• Nursing activities were carried out.

• Nursing activities were effective

• Client’s condition has changed

Which of the following represents application of the components of evaluating?

• Goal achievement must be written as either completely met or unmet.

• Data related to expected outcomes must be collected

• If the outcome was achieved, conclude that the plan was effective

• After determining that the outcome was not met, start over with a new nursing care plan.