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WorksheetsNursing Process
Total questions: 55
Worksheet time: 43mins
Which of the following is an example of an error in a nursing diagnostic/problem statement?
“Impaired Gas Exchange related to alveolar-capillary membrane changes.”
“Risk for Infection related to poor wound healing.”
“Imbalanced Nutrition: Less than Body Requirements related to refusal to eat.”
"Anxiety related to myocardial infarction"
A nurse writes: “Ineffective Coping related to laziness.”
Which type of error does this represent?
Using value-laden or judgmental language
Combining two nursing diagnoses
Reversing diagnostic label and etiology
Lack of supporting evidence
A patient is refusing meals. The nurse documents:
“Imbalanced Nutrition: Less than Body Requirements related to refusal to eat.”
How should the nurse revise this statement to avoid diagnostic error?
Keep as written because the diagnosis is correct
Change to “Imbalanced Nutrition related to metabolic disorder”
Identify a contributing factor, such as “fear of choking” or “loss of appetite”
Use a medical diagnosis instead of the refusal
A student nurse writes:
“Ineffective Coping related to laziness.”
What action should the instructor guide the student to take?
Accept the diagnosis because coping issues often involve laziness
Replace judgmental wording with an objective factor, such as “lack of support system”
Use “as evidenced by” to make the statement correct
Change “Ineffective Coping” to “Noncompliance”
A patient with newly diagnosed type 1 diabetes is admitted. Which nursing diagnosis is the priority?
Knowledge Deficit regarding disease management
Risk for Unstable Blood Glucose Level
Anxiety related to hospitalization
Risk for Impaired Skin Integrity
The nurse develops a care plan for a patient admitted with COPD. Which nursing diagnosis should the nurse address first?
Ineffective Breathing Pattern
Fatigue
Imbalanced Nutrition: Less than Body Requirements
Anxiety
A patient admitted with dehydration has the following nursing diagnoses:
•Deficient Fluid Volume
•Risk for Impaired Skin Integrity
•Knowledge Deficit regarding fluid needs
•Risk for Falls
Which diagnosis should the nurse address first?
Deficient Fluid Volume
Knowledge Deficit
Risk for Impaired Skin Integrity
Risk for Falls
A nurse is planning care for a patient with COPD who is anxious about shortness of breath. Nursing diagnoses include:
•Ineffective Breathing Pattern
•Anxiety
•Risk for Infection
•Imbalanced Nutrition: Less than Body Requirements
Which diagnosis should be the nurse’s priority?
Ineffective Breathing Pattern
Anxiety
Risk for Infection
Imbalanced Nutrition
A newly diagnosed diabetic patient has several expected outcomes. Which should the nurse prioritize?
Patient verbalizes understanding of disease process
Patient maintains blood glucose between 80–120 mg/dL during hospitalization
Patient verbalizes decreased anxiety regarding injections
Patient demonstrates correct food selection from diabetic menu
A patient with COPD has the following outcomes. Which is the most important?
Patient demonstrates proper use of inhaler
Patient verbalizes decreased anxiety about breathing
Patient maintains respiratory rate between 12–20/min with oxygen saturation above 92%
Patient reports improved appetite within 24 hours
A patient with dehydration has the following outcomes. Which one should be prioritized?
Patient demonstrates knowledge of proper fluid intake before discharge
Patient’s intake will equal output within 8 hours
Patient verbalizes reduced thirst within 4 hours
Patient ambulates 50 feet without dizziness by discharge
A patient with COPD has these outcomes:
Patient maintains O₂ saturation ≥ 92% with 2 L nasal cannula
Patient demonstrates pursed-lip breathing when short of breath
Patient verbalizes decreased anxiety about breathing
Patient consumes 75% of meals daily
Which outcome takes priority?
O₂ saturation ≥ 92%
Demonstrates pursed-lip breathing
Verbalizes decreased anxiety
Consumes 75% of meals
Which statement is correctly stated as an expected client outcome?
Client will ambulate safely.
Client will be able to safely walk down the hallway.
Nurse will assist the client with ambulation three times daily.
Client will ambulate with assistance to nurse's station on second postoperative day.
The nurse is caring for a one day postoperative client with a new colostomy. What nursing diagnosis would be the primary concern for the nurse?
Activity intolerance
Ineffective Health Maintenance
Impaired bowel elimination
Ineffective coping
The nurse knows which intervention is a dependent intervention?
Obtaining a client's BP
Massaging a client's back
Administering medications to a client
Assessing a client's lung sounds
The nurse is caring for a client recovering from a CVA (cerebrovascular accident). When reviewing orders, the nurse notes that a healthcare provider has written an order for the client to ambulate, while another has written for strict bedrest. What is the most appropriate nursing intervention?
Collaborate with the physical therapist to determine if the client can ambulate
Assess the client to determine the client's ability to ambulate
Instruct the client to clarify with the healthcare provider ambulation orders
Clarify ambulation orders with healthcare providers
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's most appropriate first action?
Discuss the frequency of pain medication orders with the client.
Assess the client to determine the cause of the pain
Consult with the healthcare provider for additional pain orders
Assist the client to reposition and splint the incision site
A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons?
Incorrect clustering of data
Wrong diagnosis
Condition is a collaborative problem
Premature ending assessment
A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, “Yes, usually twice or more.” The patient had an episode of diarrhea 1 week ago. She weighs 300 lb and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination. (Select all that apply.)
Age 42
Dysuria
Difficulty performing perineal hygiene
Nocturia
Episode of diarrhea
Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
Offer frequent skin care because of Impaired Skin Integrity
Risk of Infection
Chronic Pain related to osteoarthritis
Activity Intolerance related to physical deconditioning
Lack of Knowledge related to laser surgery
Which of the following best describe a collaborative health problem? (Select all that apply.)
An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s health status
The language medical practitioners use to communicate a patient’s health problem and associated treatments and response
A diagnostic label that classifies a patient’s response to illness so that all nurses can be familiar with a specific patient’s health care needs
A language used by health care providers to communicate and consider each other’s unique perspective, so they can better manage the multiple factors that influence the health of individuals
A diagnosis that provides clear direction as to the type of nursing interventions nurses are licensed to provide independently
Which of the following is a diagnostic error involving identification of a goal of care rather than a patient need?
Patient obtains social support care related to caregiver stress
Fear related to open-heart surgery
Acute Pain related to splinting of incision
Impaired Family Coping related to insufficient caregiver support
A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order.
1. Consider the context of patient’s health problem and select a related factor.
2. Review assessment data, noting objective and subjective clinical information.
3. Cluster clinical data elements that form a pattern.
4. Identify appropriate assessment findings for diagnosis.
5. Identify a nursing diagnosis.
(a)
A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced movement of lower leg, reduced range of motion in left knee, and difficulty turning in bed without assistance. This data set is an example of:
Collaborative data set.
Diagnostic label.
Related factors
Data cluster
Fill in the Blank:
A(n) (a) diagnosis is one that applies when there is an increased potential or vulnerability for a patient to develop a problem.
_______ assessments can be done with an initial assessment. They identify new or overlooked problems. They are important because they can "flag" existing problems.
Initial
Focused
On-going
Emergency
Time lapsed assessments compare current status to the ______data
Subjective
Projected
Objective
Baseline
_______ data is observable and measurable data that can be seen, heard, felt or measured by someone other than the person experiencing them
Objective
Subjective
_______ is the conscious and deliberate use of the five senses to gather data
Assessment
Interview
Observation
The act of confirming or verifying data is__________
Interview
Inference
Validation
The four methods used to collect data during an assessment (select all that apply)
Inspection
Palpitation
Percussion
Clarify
Auscultation
The _____ step of the nursing process interprets and analyzes data gathered
Assessment
Diagnosis
Implementation
Evaluation
The formulation of nursing diagnosis statements include
(select all that apply)
Problem
Defining characteristics
Related factors
Medical diagnosis
Etiology
Caring for a patient who presents with labored respirations, productive cough, and fever. What would be an appropriate nursing diagnosis for this patient? (select all that apply)
Bronchial pneumonia
Impaired gas exchange
Ineffective airway clearance
Potential complications: sepsis
Risk for septic shock
Which action is most important for the nurse to take to improve a client's safety?
Completing an incident report after a fall
Identifying and addressing potential risks in the client's environment
Administering medications on time
Documenting vital signs accurately
A nurse is prioritizing care using Maslow's hierarchy of needs. Which patient need should the nurse address first?
Need for self-esteem
Need for oxygen
Need for belonging
Need for education
A client has a new diagnosis of diabetes and needs education on self-care. This is an example of what priority?
High
Intermediate
Low
Emergent
What is the primary purpose of the nursing process?
To diagnose medical conditions
To provide a standardized approach to patient care
To identify and treat patient responses to health problems
To delegate tasks to other healthcare professionals
Which factor is most important when setting priorities for patient care?
The nurse's personal preferences
The availability of resources
The acuity of the patient's condition and their needs
The time of day
A nurse is teaching a patient about a new medication. Which part of the nursing process does this describe?
Assessment
Planning
Implementation
Evaluation
A nurse is caring for several clients. Which client should the nurse assess first?
A client with a chronic cough
A client with a new onset of chest pain
A client who needs assistance with bathing
A client with a scheduled medication administration
What is the best definition of a nursing diagnosis?
The identification of a disease or medical condition
A statement of a patient's response to a health problem that a nurse can treat
A physician's order for patient care
A standardized care plan for a specific medical condition
Which element is essential when writing a NANDA nursing diagnosis statement?
Patient's medical history
Related medical diagnosis
Etiology of the problem
Physician's name
A nurse is caring for a client with a risk for falls. Which intervention is the least restrictive?
Applying wrist restraints
Placing the client in a locked room
Providing frequent reorientation and assistance
Administering a sedative medication
A patient is ready to improve their nutrition. Which type of nursing diagnosis is this?
Problem-focused
Risk
Health Promotion
Syndrome
What is a high priority nursing diagnosis?
Risk for infection
Impaired gas exchange
Readiness for enhanced knowledge
Anxiety
What is an example of an activity related to clinical judgement?
Following procedure
Applying knowledge in patient situations
Completing paper work
Administering medication
What is clinical judgement?
Critical thinking
Decision making
Outcome of critical thinking and decision making
Nursing experience
What is the purpose of NANDA?
Identify potential problems
Analyze data
Nursing diagnosis statement
Gathering data
What is prioritization based on?
Acuity of problems
Patient safety
Patient needs
All of the above
A nurse is planning care for a group of clients. Which of the following clients should the nurse see first?
A client who is requesting pain medication
A client who has a new prescription for an oral medication
A client who is reporting difficulty breathing
A client who is due for routine vital signs
A goal for a patient with impaired swallowing is: "Patient will be free from aspiration during their hospitalization." Which of the following is an appropriate outcome for this goal?
The patient will report decreased pain while swallowing.
The patient will adhere to the prescribed dysphagia diet when eating all meals during the hospitalization.
The nurse will monitor the patient's swallowing ability.
The healthcare team will collaborate to manage the patient's dysphagia.
A nurse is writing a plan of care for a client. Which of the following is an example of a SMART outcome?
The patient will have improved mobility.
The patient will be free from pain.
The patient will walk 50 feet with the use of a walker by the end of the week.
The patient will understand their medications.
Which step of the nursing process involves collecting subjective and objective data from a patient?
Diagnosis
Assessment
Planning
Evaluation
Which of the following is an example of a nursing diagnosis?
Pneumonia
Hyperglycemia
Impaired Gas Exchange
Myocardial Infarction
