Chapter 05: Assessment, Nursing Diagnosis, and Planning My Nursing Test Banks

Chapter 05: Assessment, Nursing Diagnosis, and Planning

Test Bank

MULTIPLE CHOICE

1. When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _______ data.

a.

objective

b.

medical

c.

subjective

d.

adjunct

ANS: C

Subjective data are symptoms that only the patient can identify.

DIF: Cognitive Level: Application REF: p. 55 OBJ: Theory #3

TOP: Assessment Data KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

2. The major goal of the admission interview (usually performed by the RN) is to:

a.

establish rapport.

b.

help the patient understand the objectives of care.

c.

identify the patients major complaints.

d.

initiate nursing care plan forms.

ANS: C

The interview is used as part of the assessment process to elicit information about the patients physical, emotional, and spiritual health.

DIF: Cognitive Level: Comprehension REF: p. 55 OBJ: Theory #1

TOP: Interview KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

3. An example of a structured format for gathering data that aids in forming a database is:

a.

North American Nursing Diagnosis AssociationInternational (NANDA-I).

b.

Maslows hierarchy.

c.

following the information in the history and physical.

d.

Gordons 11 Health Patterns.

ANS: D

Mary Gordons assessment guide is a guided path to cover 11 health points. Although Maslow may be used, it is not structured.

DIF: Cognitive Level: Knowledge REF: p. 55 OBJ: Theory #2

TOP: Gordons 11 Health Patterns KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

4. During the assessment phase of the nursing process, the nurse

a.

develops a care plan to meet the patients nursing needs.

b.

begins to formulate plans for providing nursing intervention.

c.

establishes a nursing diagnosis for the nursing care plan.

d.

gathers, organizes, and documents data in a logical database.

ANS: D

Gathering and organizing data is the first step in the assessment phase of the nursing process.

DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #1

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

MSC: NCLEX: N/A

5. After the admission assessment is completed, on subsequent shifts or days, the nurse:

a.

does not assess the patient again unless the condition changes.

b.

refers only to the admission assessment during the hospitalization.

c.

performs a complete physical examination every day.

d.

assesses the patient briefly in the first hour of the shift.

ANS: D

The patient should be briefly assessed at the beginning of each shift and more thoroughly if his or her condition changes or as per the plan of care.

DIF: Cognitive Level: Comprehension REF: p. 59 OBJ: Theory #1

TOP: Physical Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

6. The nurse performing an admission interview on an elderly person should:

a.

rush through the interview to avoid tiring the patient.

b.

direct questions to the family rather than the patient.

c.

allow more time for a response to questions.

d.

prompt the patient to speed recall.

ANS: C

When interviewing an elderly person, allow more time because the person will probably have a more extensive history and may take a little longer to recall the needed information.

DIF: Cognitive Level: Application REF: p. 58 OBJ: Theory #5

TOP: Admission Interview KEY: Nursing Process Step: Intervention

MSC: NCLEX: Physiological Integrity: basic care and comfort

7. A nursing diagnosis consists of:

a.

the physicians medical diagnosis listed as the nursing diagnosis.

b.

diagnostic labels formulated by the North American Nursing Diagnosis AssociationInternational (NANDA-I).

c.

the patients explanation of his or her chief complaint or current complaint.

d.

the results of the nursing assessment without consideration of doctors orders.

ANS: B

NANDA-I has formulated an official list of nursing diagnoses to identify patient problems and problems that patients are at risk of developing. A nursing diagnosis is independent of a medical diagnosis.

DIF: Cognitive Level: Comprehension REF: p. 61 OBJ: Theory #5

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

MSC: NCLEX: N/A

8. An elderly patient with a medical diagnosis of chronic lung disease has developed pneumonia. She is coughing frequently and expectorating thick, sticky secretions. She is very short of breath, even with oxygen running, and she is exhausted and says she cant breathe. Based on this information, an appropriately worded nursing diagnosis for this patient is

a.

Airway clearance, ineffective, related to lung secretions as evidenced by cough and shortness of breath.

b.

Pneumonia, cough, and shortness of breath related to chronic lung disease.

c.

Difficulty breathing not relieved by oxygen and evidenced by shortness of breath.

d.

Cough and shortness of breath caused by pneumonia, chronic lung disease, advanced age, and exhaustion.

ANS: A

The nursing diagnosis from the NANDA list is complete with a cause and signs and symptoms.

DIF: Cognitive Level: Analysis REF: p. 63, Box 5-4

OBJ: Theory #5 TOP: Nursing Diagnosis

KEY: Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity: basic care and comfort

9. If a patient has several nursing diagnoses, the nurse will first:

a.

consult with the doctor regarding which diagnosis is most important.

b.

devise nursing interventions for the most quickly solved problems.

c.

prioritize the nursing problems according to Maslows hierarchy of needs.

d.

review the patients medical prescriptions and other drugs being taken.

ANS: C

Nursing diagnoses (and thus their interventions) must be prioritized to identify the order of importance based on Maslows hierarchy.

DIF: Cognitive Level: Analysis REF: p. 63, Box 5-4

OBJ: Clinical Practice #4 TOP: Prioritizing KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

10. A patient has a nursing diagnosis of Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30-pounds over the last 6 months. An appropriate short-term goal for this patient is to:

a.

eat 50% of six small meals each day by the end of 1 week.

b.

demonstrate progressive weight gain over 6 months.

c.

eat all of the meals prepared during admission.

d.

verbalize understanding of caloric needs and intention to eat.

ANS: A

Short-term goals should be realistic and attainable and should have a time line of 7 to 10 days before discharge.

DIF: Cognitive Level: Application REF: p. 63 OBJ: Clinical Practice #6

TOP: Expected Outcomes KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

11. The nursing diagnoses that has the highest priority is:

a.

Mobility, impaired physical, related to muscular weakness as evidenced by the inability to walk without assistance.

b.

Communication, impaired verbal, related to neuromuscular weakness as evidenced by facial weakness and inability to speak.

c.

Imbalanced nutrition: less than body requirements, related to difficulty swallowing and inadequate food intake as evidenced by weight loss of 10 pounds.

d.

Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating.

ANS: D

Choking and aspiration are life-threatening events and take priority over problems such as weakness, inability to speak, or weight loss.

DIF: Cognitive Level: Analysis REF: p. 62 OBJ: Clinical Practice #4

TOP: Prioritizing KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

12. A patient with visual impairment is identified as at risk for falls related to blindness. An appropriate intervention would be to:

a.

assist the patient with feeding herself at the end of the meal.

b.

arrange furnishings in room to provide clear pathways and orient the patient to these.

c.

take the patients blood pressure before she gets up in the morning.

d.

report any falls immediately to the charge nurse and the doctor.

ANS: B

Providing clear pathways directly reduces the risk of patient falls.

DIF: Cognitive Level: Analysis REF: p. 59 OBJ: Clinical Practice #6

TOP: Clinical Planning KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

13. The North American Nursing Diagnosis AssociationI (NANDA-I) list is revised and updated every:

a.

year.

b.

2 years.

c.

3 years.

d.

5 years.

ANS: B

NANDA-I meets every 2 years to revise and update the list.

DIF: Cognitive Level: Knowledge REF: p. 61 OBJ: Theory #5

TOP: NANDA-I KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

14. A nursing care plan consists of:

a.

nursing orders for individualized interventions to assist the patient to meet expected outcomes.

b.

orders for diagnostic and therapeutic procedures such as laboratory tests or radiographs.

c.

the physicians history and physical examination, as well as medical diagnoses.

d.

laboratory and radiograph reports, pathology reports, and the medication record.

ANS: A

The nursing care plan consists of the nursing orders for interventions to address problems and establish outcomes by which the plan can be evaluated.

DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: Clinical Practice #5

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

MSC: NCLEX: N/A

15. In an acute care facility, a nursing care plan is usually reviewed and updated:

a.

every shift.

b.

every 24 hours.

c.

once every 3 days.

d.

on admission and discharge.

ANS: B

Ongoing assessment, intervention, and evaluation lead to attainment or modification of the original plan for the patient who is acutely ill. The nursing care plan must be updated daily to reflect these changes.

DIF: Cognitive Level: Knowledge REF: p. 65 OBJ: Clinical Practice #6

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

MSC: NCLEX: N/A

16. The nurse takes into consideration that the difference between a sign and a symptom is that a sign is:

a.

subjective data.

b.

unreliable because it depends on translation.

c.

can be verified by examination.

d.

something a patient reports that is verified by a relative.

ANS: C

Signs are objective data that can be confirmed by examination, assessment, or observation. Signs are reliable research-based data.

DIF: Cognitive Level: Comprehension REF: p. 62 OBJ: Theory #2

TOP: Assessment (Data Collection) KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

17. The nurse clarifies that nursing orders are also called:

a.

goals.

b.

qualifiers.

c.

interventions.

d.

measurement criteria.

ANS: C

Nursing orders are also called nursing interventions and follow the same requirements when placed in a nursing care plan.

DIF: Cognitive Level: Knowledge REF: p. 65 OBJ: Theory #2

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

MSC: NCLEX: N/A

18. The nurse designs the goals for patients in long-term facilities to be:

a.

conditional.

b.

open ended.

c.

based on behavioral norms.

d.

long-term.

ANS: D

Long-term goals are more appropriate for patients in long-term facilities because they will be there for an extended period and many of their health problems are chronic.

DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: Theory #7

TOP: Long-Term Goals KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

19. Standardized Nursing Care Plans can:

a.

be documented without alteration.

b.

have items altered or deleted.

c.

become part of the record without documentation.

d.

help the family understand the concept of Nursing Care Plans.

ANS: B

Standardized Nursing Care Plans are generic and need to be altered to become individualized. They must be documented.

DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: Theory #7

TOP: Assessment (Data Collection) KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

20. A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is:

a.

Airway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung.

b.

Airway clearance, ineffective, related to right lower lobe pneumonia as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung.

c.

Right lower lobe pneumonia, related to airway clearance, ineffective, as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung.

d.

Expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung related to right lower lobe pneumonia as evidenced by airway clearance.

ANS: A

The nursing diagnosis is from the NANDA-I list and is complete with a cause and signs and symptoms. The other answers contain a medical diagnosis of pneumonia, which is inappropriate.

DIF: Cognitive Level: Analysis REF: p. 61 OBJ: Theory #7

TOP: Nursing Diagnosis KEY: Nursing Process Step: Diagnosis

MSC: NCLEX: Physiological Integrity: basic care and comfort

COMPLETION

21. Conclusions that have been made based on observed data are __________.

ANS:

inferences

Inferences are conclusions made based on observed data.

DIF: Cognitive Level: Knowledge REF: p. 61 OBJ: Theory #6

TOP: Inferences KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

MULTIPLE RESPONSE

22. The nurse understands that an expected outcome should be: (Select all that apply.)

a.

realistic.

b.

approved by the physician.

c.

attainable.

d.

within a defined time.

e.

included after patient collaboration.

ANS: A, C, D, E

An expected outcome should be realistic and attainable and should have a defined time line after collaboration with the patient.

DIF: Cognitive Level: Knowledge REF: p. 63 OBJ: Theory #6

TOP: Nursing Process KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

23. A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurologic impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.)

a.

Assist with range-of-motion exercises every 4 hours and as needed.

b.

Instruct patient to call for assistance when needing to get out of bed.

c.

Apply wrist and ankle restraints to promote safety and prevent falls.

d.

Teach about exercises that will strengthen muscles while lying in bed.

e.

Ambulate with physical therapy assistance at least three times a day.

ANS: A, B, D, E

The nurse selects appropriate nursing interventions to alleviate the problems and assist the patient in achieving the expected outcomes. Consider all possible interventions for relief of the problems and then select those most likely to be effective.

DIF: Cognitive Level: Application REF: p. 65 OBJ: Clinical Practice #5

TOP: Assessment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

24. Appropriate nursing roles in the initial assessment would include: (Select all that apply.)

a.

LPN obtains the vital signs of a new patient.

b.

RN performs a complete physical assessment.

c.

LPN organizes data into a database.

d.

RN reviews the patients chart for past medical/surgical history.

e.

LVN contributes ongoing assessments.

ANS: A, B, D, E

The LPN/LVN, under the NFLPN standard, contributes assessments; the RN performs the physical assessment and medical records review and organizes the database.

DIF: Cognitive Level: Comprehension REF: p. 61 OBJ: Theory #2

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

25. Aside from the information obtained from the patient (primary source) in the admission interview, the nurse will also access: (Select all that apply.)

a.

the patients family.

b.

a reliable and up-to-date reference book.

c.

the admission note.

d.

the physicians history and physical.

e.

an observation of the patient for non-verbal clues.

ANS: A, C, D, E

The nurse conducting the interview uses information from the patients family, from the physicians admission note and history and physical, and from personal observation of the patient.

DIF: Cognitive Level: Comprehension REF: p. 55 OBJ: Theory #2

TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

26. A nursing diagnosis identifies: (Select all that apply.)

a.

patients response to illness.

b.

related signs and symptoms.

c.

underlying medical diagnosis.

d.

causative factors.

e.

potential risk for health problems.

ANS: A, B, D, E

Defining characteristics of nursing diagnosis include the patients response to illness and the causative factors. Signs and symptoms must also be identified for a nurse to select an appropriate nursing diagnosis. Medical diagnoses label an illness; nursing diagnoses are independent of medical diagnoses.

DIF: Cognitive Level: Comprehension REF: p. 61 OBJ: Theory #5

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

MSC: NCLEX: N/A

27. The statements that are correctly stated as expected outcomes are: (Select all that apply.)

a.

Patient will be able to void in the bathroom independently.

b.

Patient will be able to ambulate using a walker independently within 3 days.

c.

The nurse will assist the patient to the bathroom three times a day.

d.

Patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours.

e.

The family will bring food from home to improve patient appetite.

ANS: B, D

Expected outcomes need to have a time frame and be measurable. Ambulating with a walker within three days and performing ROM independently for four hours are both measurable outcomes with clear time frames. The outcome of voiding independently does not have a time frame. Assisting the patient to the bathroom is a nursing intervention.

DIF: Cognitive Level: Comprehension REF: p. 63 OBJ: Theory #6

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

MSC: NCLEX: N/A

28. The nurse should make a point when closing the initial interview to: (Select all that apply.)

a.

develop rapport.

b.

summarize the problems discussed.

c.

thank the patient for his or her time.

d.

discuss the nursing goals associated with nursing diagnoses.

e.

give a copy of the nursing care plan to the patient.

ANS: B, C

The nurse should summarize the problems discussed, thank the patient for his or her time, and explain what happens next and when the nurse will return.

DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #1

TOP: Nursing Process KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

29. The seven domains of the Nursing Interventions Classification (NIC) taxonomy include: (Select all that apply.)

a.

community.

b.

health system.

c.

socioeconomic level.

d.

safety.

e.

behavioral.

ANS: A, B, D, E

The seven domains of the NIC taxonomy are: physiological: basic; physiological: complex; behavioral; safety; family; health system; and community.

DIF: Cognitive Level: Knowledge REF: p. 65 OBJ: Theory #5

TOP: NIC KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

30. The purpose of the Nursing Outcomes Classification (NOC) is to: (Select all that apply.)

a.

validate classification by field test.

b.

identify labels.

c.

provide language labels for desired outcomes.

d.

generate a ready-made nursing care plan for a patient.

e.

identify patient outcomes and indicators.

ANS: A, B, C, E

The purpose of NOC is to provide language labels to help identify and classify patient outcomes and validate classifications by field testing.

DIF: Cognitive Level: Knowledge REF: p. 64 OBJ: Theory #6

TOP: NOC KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

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