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Nursing Process

Total questions: 25

Worksheet time: 13mins

Name
Class
Date
1.

The purpose of stating a two part diagnosis created after identifying a relationship between the health problem (stem) and factors related to the health problem (etiology) is to:

a)

individualize the plan of nursing care for the patient.

b)

include both dependent and independent nursing functions.

c)

compare the patient’s problems to accepted standards.

d)

use a functional category approach to organize the assessment data.

2.

The stem part of the nursing diagnosis statement guides the nurse in developing which other part of the nursing care plan?

a)

goal/outcome

b)

intervention

c)

evaluation

d)

etiology

3.

Name the steps of the nursing process

a)

assessment, diagnosis, planning, intervention, evaluation

b)

assessment, diagnosis, planning, implementation, evaluation

c)

acknowledge, decision-making, planning, implementation, evaluation

d)

assessment, decision-making, planning, intervention, evaluation

4.

What are two types of nursing diagnosis?

a)

direct and indirect

b)

independent and collaborative

c)

actual and potential

d)

independent and dependent

5.

Which of the following is/are subjective assessment data?

a)

chest pain

b)

IV site infiltration

c)

scalp itching

d)

A and C

e)

All of the above

6.

Which of the following are valid sources for patient assessment data?

a)

patient's family

b)

medical record/chart

c)

healthcare team

d)

All of the above

7.

What are the parts of the nursing diagnosis statement.

a)

assessment, diagnosis, plan, implementation, evaluation

b)

actual and potential

c)

cause and effect

d)

problem, etiology, symptoms

8.

The medical diagnosis is never included as a part of the nursing diagnosis.

a)

True

b)

False

9.

The "risk for" nursing diagnosis contains:

a)

etiology

b)

symptoms

c)

both etiology and symptoms

d)

neither etiology or symptoms

10.

Nursing interventions are guided by:

a)

the NANDA list

b)

the problem or stem of the nursing diagnosis

c)

the etiology of the nursing diagnosis

d)

the symptoms or defining characteristics

11.

Which of the following terms defines the "patient's response to a disease or medical condition"?

a)

nursing diagnosis

b)

medical diagnosis

c)

interventions

d)

medical diagnosis

12.

SMART characteristics are used for:

a)

goals

b)

outcomes

c)

interventions

d)

evaluations

13.

Which of the following would be appropriate to use when writing an outcome using SMART criteria?

a)

understand

b)

know

c)

demonstrate

d)

feel

14.

The implementation phase of the nursing care plan should include:

a)

evaluation of the nursing care plan

b)

patient teaching

c)

identifying a nursing diagnosis

d)

selection of the nursing diagnosis

15.

Goals and outcomes should be:

a)

written after determining patient interventions

b)

written before developing a nursing diagnosis

c)

evaluated based on doctor's orders

d)

evaluated and labeled as met, unmet, partially met

16.

The nurse’s initial actions as part of the evaluation phase are activities directed at assessing for:

a)

scope of support data

b)

accuracy of the nursing diagnoses

c)

measurability of the goals/outcomes

d)

effects of the stated nursing interventions

17.

Which option best reflects nursing activities that occur within the implementation phase of the nursing process?

a)

Obtaining the patient’s subjective rating of pain one hour after analgesia is given

b)

Administering a dose of analgesia to a patient experiencing pain

c)

Determining criteria that will reflect successful pain relief activities

d)

Modifying the outcome after assessing reaction to the analgesia

18.

Which of the following will help the nurse prioritize needs?

a)

identifying a problem, cause of the problem, and defining characteristics

b)

ensuring assessment data is thorough and complete

c)

utilization of Maslow's Hierarchy

d)

assessment, teaching, and evaluation

19.

Which of the following is a well written nursing diagnosis statement?

a)

Risk for infection R/T infection via surgical incision​

b)

Altered oral mucous embranes R/T forceful trauma during oral suctioning​

c)

Breathing pattern, ineffective, R/T retained secretions secondary to pulmonary edema​

d)

Decreased caloric intake R/T alteration in nutrition

20.

During the assessment phase for the nursing process, the most unreliable source for accurate patient data would be:

a)

a health care provider’s dictated History & Physical

b)

responses from a patient determined to be awake & oriented X1 (A&Ox1)

c)

the patient’s significant other.

d)

report from the nursing staff at change of shift.

21.

Collection of data in a systematic and organized manner during the initial assessment phase allows the nurse to:

a)

predict patient responses to nursing interventions

b)

change the nursing tasks identified in the plan of care

c)

recognize elements of relevant data that are missing

d)

complete the chart documentation in an organize manner

22.

The nurse understands the following statement " The patient will reduce his risk of falls by correct use of his walker each time him ambulates" is an example of...

a)

nursing diagnosis

b)

outcome

c)

goal

d)

intervention

23.

If the client has not completed the care plan, but the goal is still relevant...

a)

create a new plan

b)

reassess in 24 hours

c)

initiate new interventions

d)

adjust diagnosis to suit the outcome

24.

Which of the following is true about interventions?

a)

may assist with data collection

b)

broadly applied to all patients

c)

connect patients goals and outcomes

d)

improve the relationship between nursing and allied health

25.

Which of the following is objective data?

a)

client reports a fever

b)

itching

c)

headache

d)

temp of 99.1