Chapter 04: Nursing Process and Critical Thinking My Nursing Test Banks

Chapter 04: Nursing Process and Critical Thinking

Test Bank

MULTIPLE CHOICE

1. The nurse who uses the nursing process will:

a.

help reduce the obvious signs of discomfort.

b.

help the patient adhere to the physicians treatment protocol.

c.

approach the patients disorder in a step-by-step method.

d.

make all significant nursing care decisions involving patient care.

ANS: C

The nursing process is a collaborative process used throughout the patients stay. It is an organized method for identifying and meeting patient needs in a step-by-step manner.

DIF: Cognitive Level: Knowledge REF: p. 46 OBJ: Theory #1

TOP: Nursing Process KEY: Nursing Process Step: Assessment

MSC: NCLEX: N/A

2. A nurse will arrive at a nursing diagnosis through the nursing process step of:

a.

planning.

b.

evaluation.

c.

research.

d.

assessment.

ANS: D

As a result of the nursing assessment, a nursing diagnosis is established.

DIF: Cognitive Level: Comprehension REF: p. 46 OBJ: Theory #2

TOP: Nursing Diagnosis KEY: Nursing Process Step: Assessment

MSC: NCLEX: N/A

3. In the collaborative process of delivering care based on the nursing process, the responsibility of the LPN/LVN is to:

a.

collect data of health status.

b.

select a nursing diagnosis.

c.

organize data to help the RN evaluate patient progress.

d.

prioritize nursing diagnoses for more effective care.

ANS: A

The LPN/LVN collects data of the patients health status to assist the RN in selecting a nursing diagnosis.

DIF: Cognitive Level: Comprehension REF: p. 46, Table 4-1

OBJ: Theory #2 TOP: Critical Thinking

KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

4. The participants of the planning stage of the nursing process during which the health goals are defined include the:

a.

RN.

b.

health team led by the RN.

c.

health team, the patient, and the patients family.

d.

health team as directed by the physician.

ANS: C

The planning stage during which the health goals are defined are best shared by the entire health team, the patient, and the patients family for the optimum outcome.

DIF: Cognitive Level: Comprehension REF: p. 46 OBJ: Theory #1

TOP: Nursing Process KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

5. When a resident in the nursing home complains of constipation, the nurse performs a digital rectal examination and finds a hard fecal mass. This is an example of:

a.

implementation.

b.

nursing diagnosis.

c.

assessment.

d.

evaluation.

ANS: C

The examination to confirm and affirm the complaint of constipation is an assessment.

DIF: Cognitive Level: Application REF: p. 47, Table 4-1

OBJ: Theory #1 TOP: Nursing Process

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

6. The nurse completing morning assessments on a patient who is sitting up in bed is told by the patient, Im having trouble breathingI cant seem to get enough air. The best nursing response is to:

a.

notify the doctor as soon as he or she comes in later in the morning.

b.

finish the vital signs for the assigned patients, and then notify the charge nurse.

c.

reassure the patient, if his blood pressure and pulse are normal.

d.

notify the charge nurse immediately of the patients statement.

ANS: B

The nurse should finish the assessment in order to confirm the complaint and inform the charge nurse.

DIF: Cognitive Level: Analysis REF: p. 47 OBJ: Theory #1

TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

7. The order in which the nursing process is approached is:

a.

planning, assessment, implementation, nursing diagnosis, evaluation.

b.

nursing diagnosis, evaluation, assessment, implementation, planning.

c.

assessment, nursing diagnosis, planning, implementation, evaluation.

d.

evaluation, nursing diagnosis, planning, implementation, assessment.

ANS: C

The order of assessment, nursing diagnosis, planning, implementation, and evaluation sets up a basis for an organized approach to nursing care.

DIF: Cognitive Level: Knowledge REF: p. 47, Box 4-1

OBJ: Theory #1 TOP: Nursing Process KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

8. Once the nursing plan has been initiated, the nursing care plan will:

a.

stay in place until all nursing goals have been met.

b.

change as the patients condition changes.

c.

remain on the patient record to show progress.

d.

be given to the patient for final approval.

ANS: B

The nursing care plan is always a work in progress and will change as the patient condition changes.

DIF: Cognitive Level: Comprehension REF: p. 46 OBJ: Theory #2

TOP: Nursing Process KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

9. When a patient states, I cant walk very well, the first problem-solving step would be to:

a.

consider alternatives such as a wheelchair or walker.

b.

find out what the problem is, such as weakness or poor balance.

c.

choose the alternative with the best chance of success.

d.

consider the outcomes of the choices, such as danger of falling with a walker.

ANS: B

Defining the problem clearly assists in the interventions to reduce the problem.

DIF: Cognitive Level: Analysis REF: p. 48 OBJ: Theory #5

TOP: Problem Solving KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

10. A student nurse can begin to develop critical thinking skills by means of:

a.

working with a more experienced nurse.

b.

questioning every statement made by instructors to be sure of its correctness.

c.

memorizing class notes for tests and studying all night for big tests.

d.

listening attentively and focusing on the speakers words and meaning.

ANS: D

Critical thinking involves foundation skills such as effective reading and writing and attentive listening.

DIF: Cognitive Level: Comprehension REF: p. 48 OBJ: Theory #7

TOP: Critical Thinking KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

11. When a nurse prioritizes the patient care, consideration is given to:

a.

completing assessments before mid-shift.

b.

considering situations that may result in an alteration of health.

c.

assuming all health care activities for a group of patients.

d.

identifying who can assist with the aspect of care.

ANS: B

Priority setting includes addressing health-endangering situations and physiological needs first.

DIF: Cognitive Level: Comprehension REF: p. 50 OBJ: Theory #9

TOP: Priority Setting KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

12. When the nurse checks to see whether a patient has had relief 45 minutes after administering pain medication, the nurse is performing a(n):

a.

nursing diagnosis.

b.

implementation.

c.

assessment.

d.

evaluation.

ANS: D

Evaluation is the step in which the nurse determines whether the plan and interventions are effective or need to be modified.

DIF: Cognitive Level: Comprehension REF: p. 46, Box 4-1

OBJ: Theory #2 TOP: Nursing Process

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: basic care and comfort

13. The activity that is implementation in nursing care is:

a.

checking the assigned patients blood pressure, pulse, and respiration.

b.

changing the patients surgical dressing.

c.

asking the patient to demonstrate how to give himself medication after teaching him.

d.

discussing the patient with other team members to establish a care plan.

ANS: B

Changing a dressing that is soiled is a nursing intervention performed to meet a patients need. Checking vital signs is assessment. Demonstrating medication administration is evaluation. Discussing the patient with other team members is planning.

DIF: Cognitive Level: Comprehension REF: p. 46, Box 4-1

OBJ: Theory #2 TOP: Implementation KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

14. Constant nursing assessments and evaluations of the patient will most likely result in:

a.

the nursing care plan changing to reflect appropriate priorities.

b.

small changes in the patient condition being overlooked.

c.

cluttered and confusing documentation.

d.

impeded problem solving.

ANS: A

Continued assessment and evaluation are necessary; reprioritizing and reorganizing activities occur in response to the patients changing condition.

DIF: Cognitive Level: Application REF: p. 46 OBJ: Theory #1

TOP: Nursing Process KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

15. The effect of using a scientific problem-solving approach in nursing care will cause decision making to be:

a.

slowed down considerably by the multiple steps.

b.

rigid and non-patient oriented.

c.

improved nursing care outcomes.

d.

unrelated to the nursing process.

ANS: C

A scientific problem-solving approach is most likely to result in positive patient outcomes.

DIF: Cognitive Level: Comprehension REF: p. 48 OBJ: Theory #3

TOP: Problem Solving KEY: Nursing Process Step: Planning

MSC: NCLEX: N/A

16. An emergency room nurse will give first priority to the patient with the most critical need, which is the patient who:

a.

is bleeding from a chin laceration.

b.

complains of a productive cough.

c.

has a fever of 102 F.

d.

complains of severe chest pain.

ANS: D

Because the chance of a bad outcome is highest for the patient with chest pain, it is most appropriate to assess this patient first.

DIF: Cognitive Level: Analysis REF: p. 50 OBJ: Theory #8

TOP: Critical Thinking KEY: Nursing Process Step: Assessment

MSC: NCLEX: N/A

COMPLETION

17. When the nurse constructs a nursing approach after careful judgment and sound reasoning, the nurse has used a system of __________.

ANS:

critical thinking

Critical thinking is a concept in which decisions are made using solidly based judgments and reasoning.

DIF: Cognitive Level: Knowledge REF: p. 47 OBJ: Theory #2

TOP: Critical Thinking KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

18. Critical thinking is considered to be the keystone and foundation of the development of _________.

ANS:

clinical judgment

Clinical judgment is built on the ability to think critically.

DIF: Cognitive Level: Knowledge REF: p. 47 OBJ: Theory #2

TOP: Critical Thinking KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

19. The tasks of synthesizing data and linking nursing interventions with patient health problems are enhanced by the process of ________.

ANS:

concept mapping

Concept mapping is a method to promote critical thinking by visualizing relationships between patient health problems and effective intervention.

DIF: Cognitive Level: Knowledge REF: p. 49 OBJ: Theory #3

TOP: Concept Mapping KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

MULTIPLE RESPONSE

20. Activities considered to be aspects of the implementation step of the nursing process are: (Select all that apply.)

a.

documentation of care given.

b.

assembly of supplies.

c.

analysis of data gathered.

d.

modification of aspects of the plan.

e.

evaluation of the patient response.

ANS: A, B

Documentation of care and assembly of supplies are nursing interventions performed during the implementation step of the nursing process.

DIF: Cognitive Level: Comprehension REF: p. 49 OBJ: Theory #2

TOP: Nursing Process KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

21. Descriptions of the activities involved in the nursing diagnosis step of the nursing process are: (Select all that apply.)

a.

determination of potential health problems.

b.

clustering of related assessments.

c.

sharing of information with the patient and physician.

d.

determination of desired outcomes.

e.

evaluation of probable outcomes.

ANS: A, B

During the nursing diagnosis step, assessment data are analyzed and clustered to determine health problems, and appropriate nursing diagnoses are selected.

DIF: Cognitive Level: Comprehension REF: p. 49 OBJ: Theory #1

TOP: Nursing Process KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

22. Which of the following items could be the responsibility of the LPN/LVN for a patients plan of care? (Select all that apply.)

a.

Collect data.

b.

Perform nursing interventions.

c.

Initiate the plan of care.

d.

Assist the RN with evaluation of the patients response to nursing interventions.

e.

Document nursing care.

ANS: A, B, D

Registered nurses are officially responsible for the initiation of nursing care plans for each patient, but the LPN/LVN assists with each part of the care plan. The LPN/LVN is often responsible for data collection to assist the RN with the assessment phase.

DIF: Cognitive Level: Comprehension REF: p. 46, Table 4-1

OBJ: Theory #2 TOP: Nursing Process KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

OTHER

23. A nurse begins rounds on a medicalsurgical nursing unit. Review the following patients on her assignment. Prioritize the order in which the patients should be assessed, based on their descriptions. (Separate letters with a comma and space as follows: A, B, C, D.)

A. A 22-year-old patient who is awakening from neck surgery.

B. An 82-year-old patient who is blind and needs discharge instructions.

C. A 44-year-old patient with dehydration from vomiting and diarrhea, who was admitted 3 days ago and who has an IV infusion of fluids.

D. A 35-year-old patient admitted for an injury to his left femoral artery, which required surgical repair 8 hours ago following an ice-skating accident.

ANS:

A, D, C, B

Nursing priorities need to address patients with life-threatening concerns first. A patient just awakening from neck surgery needs to be assessed first because of the concerns of tracheal swelling. A patient with a compromised limb is the next priority. The patient on IV fluids for dehydration is next. The patient for discharge is the last priority.

DIF: Cognitive Level: Analysis REF: p. 50 OBJ: Theory #9

TOP: Prioritizing KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

24. Place the steps of the problem-solving approach in the appropriate order. (Separate letters with a comma and space as follows: A, B, C, D, E.)

A. Predict the likelihood of each outcome occurring.

B. Choose the alternative with the best chance of success.

C. Consider all possible alternatives as the solution to the problem.

D. Identify the problem.

E. Examine possible outcomes of each alternative.

ANS:

D, C, E, A, B

The problem-solving approach requires that a problem be clearly identified, all possible alternative solutions be examined, outcomes of solutions be considered, probability of outcome occurring be predicted, and the best alternative be chosen.

DIF: Cognitive Level: Knowledge REF: p. 50 OBJ: Theory #4

TOP: Problem Solving KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

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