Chapter 5: Nursing Process and Critical Thinking My Nursing Test Banks

Chapter 5: Nursing Process and Critical Thinking

Cooper and Gosnell: Foundations and Adult Health Nursing, 7th Edition

MULTIPLE CHOICE

1.What best defines the nursing process?

a. A method to ensure that the physicians orders are implemented correctly.
b. A series of assessments that isolate a patients health problem.
c. A framework for the organization of individualized nursing care.
d. A preset formula for the design of nursing care.

ANS: C

The nursing process is a framework by which to organize individualized nursing care.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 78

OBJ: 1 TOP: Nursing process KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

2.All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment?

a. 53-year-old admitted with a perforated ulcer
b. 5-year-old admitted for the implant of grommets in the middle ear
c. 76-year-old admitted for a knee replacement
d. 40-year-old admitted for possible bowel obstruction

ANS: A

A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses.

PTS: 1 DIF: Cognitive Level: Application REF: Page 79

OBJ: 2 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3.What subjective data does the nurse record following a head-to-toe examination?

a. Rash on back
b. Prolonged nausea
c. Blood pressure of 190/100
d. White blood cell count of 19,000

ANS: B

Another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient.

PTS: 1 DIF: Cognitive Level: Application REF: Page 79

OBJ:3TOP:Subjective data

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4.What objective data should the nurse include after a patient assessment?

a. Headache of 3 days duration
b. Severe stomach cramps
c. Flatulence
d. Anxiety

ANS: C

Objective data are observable and measurable by people other than the patient.

PTS: 1 DIF: Cognitive Level: Application REF: Page 79

OBJ:3TOP:Objective data

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5.What is classified as information provided by the family when a patient is unable to provide data during assessment?

a. Primary
b. Secondary
c. Unreliable
d. Biased

ANS: B

Secondary sources include family members.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 79-80

OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC:NCLEX: N/A

6.What are the two primary methods used to collect data?

a. Written report by patient and family
b. Review of the chart and the nurses notes
c. Interview and physical examination
d. Review of the physicians orders and the Kardex

ANS: C

The two primary methods of collecting data are interviewing and physical examination.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 79-80

OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC:NCLEX: N/A

7.The nurse writes two nursing diagnoses: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses?

a. The second diagnosis needs no defined nursing interventions.
b. The second diagnosis needs medical intervention.
c. The second diagnosis will not need to be evaluated.
d. The second diagnosis reflects a problem that does not yet exist.

ANS: D

The actual nursing diagnosis represents a condition that is currently present. Risk for diagnoses are those that the patient is susceptible to, but not yet troubled by.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83

OBJ:4TOP:Nursing diagnosis

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

8.What framework does the establishment of priorities of care during the planning phase of the nursing process often use?

a. Eriksons developmental tasks
b. Piagets cognitive table
c. Maslows hierarchy of needs
d. Freuds classifications

ANS: C

A useful framework to guide prioritization is Maslows hierarchy of needs.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 85

OBJ:9TOPriorities of care

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

9.What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions?

a. The patient will increase intake to 1000 mL daily to liquefy secretions.
b. The patient will cough more frequently within 3 days.
c. The patient will breathe better within 3 days.
d. The patient will perform deep-breathing exercises four times daily.

ANS: A

The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within 3 days is too vague.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 84

OBJ:6TOP:Nursing diagnosis

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

10.What is the primary purpose of nursing orders?

a. To support physicians orders
b. To provide direction for all caregivers
c. To provide broad, general statements
d. To clarify nursing principles

ANS: B

Nursing orders are necessary to provide instructions for all caregivers.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 85-86

OBJ:7TOP:Nursing orders

KEY:Nursing Process Step: PlanningMSC:NCLEX: N/A

11.What documentation reflects implementation?

a. Patient selected low-sugar snacks independently.
b. Patient was medicated with Tylenol 500 mg PO for pain.
c. Patient was ambulated for 15 minutes after lunch.
d. Patient participated in group therapy session without reminder.

ANS: C

Implementation is the nurse carrying out nursing orders to promote outcome achievement.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 87-88

OBJ:2TOP:Implementation

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

12.Which nursing order is complete and correct?

a. May 10: Nursing assistants will ambulate patient. A. Nurse
b. Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse
c. Nursing assistants will serve 8 oz glass of juice at each meal, 5/10.
d. P.M. nurse will ensure that heel protectors are in place before bedtime.

ANS: B

Nursing orders must be signed, dated, and have specific designation as to who will perform intervention and specifics about time or frequency of the intervention.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 85-86

OBJ:7TOP:Nursing orders

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13.A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred?

a. Omission
b. Variance
c. Failure
d. Error

ANS: B

A variance occurs when a projected outcome is not met.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 90

OBJ:8 | 11TOP:Critical pathways

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

14.During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a nursing diagnosis plan. What does this data represent?

a. Symptoms
b. Data clustering
c. Signs of fluid overload
d. Urinary retention

ANS: B

The nurse organizes data, and those that are related are referred to as clustering.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 80

OBJ: 3 | 12 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

15.What type of assessment is performed continuously throughout nurse-patient contact?

a. Complete
b. Body systems
c. Focused
d. Subjective

ANS: C

Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 79

OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC:NCLEX: N/A

16.What assists the nurse in the identification of nursing diagnoses?

a. Objective data
b. Subjective data
c. Data clustering
d. Validated data

ANS: C

Data clustering assists the nurse in determining nursing diagnoses.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83

OBJ:4TOP:Nursing diagnosis

KEY:Nursing Process Step: AssessmentMSC:NCLEX: N/A

17.What organized approach might the nurse use when performing a complete physical examination?

a. Maslows hierarchy of needs
b. A head-to-toe assessment
c. Subjective data collection
d. Objective data collection

ANS: B

A head-to-toe format provides a systematic approach.

PTS: 1 DIF: Cognitive Level: Application REF: Page 79

OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment

MSC:NCLEX: N/A

18.Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis?

a. Physician
b. LPN/LVN
c. RN
d. Technician

ANS: C

The RN is responsible for analyzing and interpreting data.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 80

OBJ: 4 TOP: Role responsibility KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

19.What is the basis for designing and selecting nursing interventions to meet patient needs?

a. Nursing diagnosis
b. Care plan
c. Physicians orders
d. Nurses notes

ANS: A

The nursing diagnosis is the basis for developing nursing interventions.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 80

OBJ:4TOP:Nursing diagnosis

KEY:Nursing Process Step: PlanningMSC:NCLEX: N/A

20.The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation?

a. Contributing to the patients recovery
b. A risk factor
c. Difficult to maintain
d. A nursing responsibility

ANS: B

Risk factors are those that increase the susceptibility of a patient to a problem.

PTS: 1 DIF: Cognitive Level: Application REF: Page 82

OBJ: 5 TOP: Risk factors KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity

21.What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking?

a. A syndrome nursing diagnosis
b. An actual nursing diagnosis
c. A risk for diagnosis
d. A possible nursing diagnosis

ANS: D

A possible nursing diagnosis requires additional data to confirm a problem or to complete a data cluster so that it can be related to a NANDA-I label.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83

OBJ:4 | 10TOP:Nursing diagnosis

KEY:Nursing Process Step: AssessmentMSC:NCLEX: N/A

22.When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process?

a. Assessment
b. Planning
c. Implementation
d. Evaluation

ANS: B

During the planning phase, the nurse connects nursing interventions to nursing orders.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 85

OBJ:2TOP:Nursing process

KEY:Nursing Process Step: PlanningMSC:NCLEX: N/A

23.What is an important consideration when developing the care plan?

a. Ensure the number of interventions is limited
b. Ensure the patient is involved in the process
c. Ensure interventions will be easy to implement
d. Ensure evaluation of the nursing diagnoses is possible

ANS: B

Plans are more effective when the patient is involved in the process. The care plan is not limited in terms of the number of interventions, nor do they have to be easy. The nursing diagnoses are not evaluated; the patients progress toward the outcome is.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 85

OBJ: 6 | 9 TOP: Care plan KEY: Nursing Process Step: Planning

MSC:NCLEX: N/A

24.From where are the risk for nursing diagnoses identified?

a. The care plan
b. The interventions
c. The assessment
d. The evaluation

ANS: C

Nursing diagnoses should be identified from the assessment.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 82-83

OBJ:2TOP:Nursing process

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

25.What expected outcome exemplifies accepted criteria?

a. Nurse will assess vital signs every day
b. Resident will observe safety guidelines while smoking
c. Resident will take part in one activity daily for the next 90 days
d. Nurse will monitor O2 saturation to maintain at greater than 90%

ANS: C

Expected outcomes must be patient-centered, measurable, and refer to a time frame.

PTS: 1 DIF: Cognitive Level: Application REF: Page 84

OBJ:6TOP:Nursing process

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

26.During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

a. The patient complains of nausea.
b. The patient is vomiting.
c. The patient experiences tachycardia.
d. The patent is pacing the halls.

ANS: A

Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of nausea is an example of subjective data. All other options are examples of objective data.

PTS: 1 DIF: Cognitive Level: Application REF: Page 79

OBJ:1 | 3TOP:Subjective data

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

27.During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

a. The patient is asleep.
b. The patient is tearful.
c. The patient has facial grimacing.
d. The patient states, I hurt all over.

ANS: D

Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Stating I hurt all over is an example of subjective data. All other options are examples of objective data.

PTS: 1 DIF: Cognitive Level: Application REF: Page 79

OBJ:1 | 3TOP:Nursing process

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

28.During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

a. The patient is coughing.
b. The patient has cyanosis of the lips.
c. The patient experiences tachypnea.
d. The patient complains of generalized discomfort.

ANS: D

Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of generalized discomfort is an example of subjective data. All other options are examples of objective data.

PTS: 1 DIF: Cognitive Level: Application REF: Page 79

OBJ:1 | 3TOP:Subjective data

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

29.During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

a. The patient complains of chest pain.
b. The patient states, I feel nauseous.
c. The patient complains of feeling faint.
d. The patient is short of breath on exertion.

ANS: D

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Shortness of breath on exertion is an example of objective data. All other options are examples of subjective data.

PTS: 1 DIF: Cognitive Level: Application REF: Page 79

OBJ:1 | 3TOP:Objective data

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

30.During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

a. The patient is jaundiced.
b. The patient states, I am nervous.
c. The patient complains of palpitations.
d. The patient denies dizziness when ambulating.

ANS: A

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. The patient is jaundiced is an example of objective data. All other options are examples of subjective data.

PTS: 1 DIF: Cognitive Level: Application REF: Page 79

OBJ:1 | 3TOP:Objective data

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

31.During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

a. The patient complains of feeling depressed.
b. The patient states, I hear voices in my head.
c. The patient complains of auditory hallucinations.
d. The patient is pacing back and forth while chanting.

ANS: D

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Pacing back and forth while chanting is an example of objective data. All other options are examples of subjective data.

PTS: 1 DIF: Cognitive Level: Application REF: Page 79

OBJ:1 | 3TOP:Objective data

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

32.What is an example of an appropriate nursing diagnosis?

a. Impaired skin integrity
b. Skin breakdown noted
c. Turn patient every 2 hours
d. The patient has scabies on his back

ANS: A

Impaired skin integrity is an example of a nursing diagnosis. Skin breakdown noted is an example of a charting entry, turn patient every 2 hours is a nursing intervention, and scabies is a medical diagnosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83

OBJ:4TOP:Nursing diagnosis

KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity

33.What is an example of an appropriate nursing diagnosis?

a. Constipation
b. Patient complains of constipation
c. Need for laxatives
d. Patient has a duodenal ulcer

ANS: A

Constipation is an example of a nursing diagnosis, a patient complaining of constipation is an example of a charting entry, a need for laxatives is an example of a patient need, and a patient has a duodenal ulcer is an example of a medical diagnosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83

OBJ:4TOP:Nursing diagnosis

KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity

34.A nurse is formulating a nursing diagnosis. What is an example of an appropriately written nursing diagnosis?

a. Risk for impaired skin integrity related to physical immobilization
b. Physical immobilization secondary to risk for impaired skin integrity
c. Risk for impaired skin integrity related to diagnosis of decubitus ulcers
d. Physical immobilization secondary to decreased cognitive ability

ANS: A

Risk for impaired skin integrity related to physical immobilization is the only appropriately written nursing diagnosis. All other options are not listed as NANDA-I approved nursing diagnoses.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 81-83

OBJ:4TOP:Nursing diagnosis

KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity

35.Which is an example of a nursing diagnosis?

a. Pneumonia
b. Diabetes mellitus
c. Impaired skin integrity
d. Congestive heart failure

ANS: C

Impaired skin integrity is the only example of a nursing diagnosis; all other options are examples of medical diagnoses.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83

OBJ:4TOP:Nursing diagnosis

KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity

36.Which is an example of a medical diagnosis?

a. Constipation
b. Diabetes mellitus
c. Impaired skin integrity
d. Altered nutrition: less than body requirements

ANS: B

Diabetes mellitus is the only example of a medical diagnosis; all other options are examples of nursing diagnoses.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 83

OBJ:4TOP:Medical diagnosis

KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity

37.Which is an example of a medical diagnosis?

a. Pain
b. Anxiety
c. Pneumonia
d. Impaired skin integrity

ANS: C

Pneumonia is the only example of a medical diagnosis; all other options are examples of nursing diagnoses.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 83

OBJ:4TOP:Medical diagnosis

KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

38.Which are acceptable secondary sources for data? (Select all that apply.)

a. Patient
b. Family members
c. Other health professionals
d. Diagnostic reports
e. Textbooks

ANS: B, C, D, E

A patient is not a secondary source. The patient is the primary data source.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 79-80

OBJ: 3 TOP: Data sources KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

39.Which are official categories of nursing diagnoses? (Select all that apply.)

a. Actual
b. Risk
c. Wellness
d. Syndrome
e. Potential

ANS: A, B, C, D

Actual, risk, wellness, and syndrome are the four categories of nursing diagnoses.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83

OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

40.Which are considered phases of the nursing process? (Select all that apply.)

a. Diagnosis
b. Prediction
c. Assessment
d. Evaluation
e. Implementation
f. Outcome identification

ANS: A, C, D, E, F

The nursing process consists of six dynamic and interrelated phases: diagnosis, assessment, outcome identification, planning, implementation, and evaluation. Prediction is not a phase of the nursing process.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 78

OBJ: 2 TOP: Nursing process KEY: Nursing Process Step: All

MSC:NCLEX: N/A

COMPLETION

41.NANDA International meets to reorganize diagnosis labels and language every ______ years.

ANS:

2

NANDA meets every 2 years to revise language, form, and diagnosis labels.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 81

OBJ: 10 TOP: NANDA KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

42.The standards that name and measure patient outcomes are referred to as ___________.

ANS:

NOC (Nursing Outcome Classification)

NOC

Nursing Outcome Classification

NOC sets up outcome criteria based on a patient problem.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 88-89

OBJ: 10 TOP: NOC KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

43.The document that outlines a multidisciplinary plan for care interventions over a specified time frame is a _______ ________.

ANS:

clinical pathway

critical path

A clinical pathway is an organized multidisciplinary plan over a specified time frame, which outlines aspects of patient care. They are also called critical paths, action plans, and care maps.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 90

OBJ: 11 TOP: Clinical pathways KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

44.A systematic method by which nurses plan and provide care for patients is known as the _________ ____________.

ANS:

nursing process

The nursing process serves as the organizational framework for the practice of nursing. It is a systematic method by which nurses plan and provide care for patients.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 78

OBJ: 2 TOP: Nursing process KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

45.A systemic, dynamic process by which the nurse, through interaction with the patient, significant others, and health care providers, collects and analyzes data about the patient is known as ______________________.

ANS:

assessment

The American Nurses Association (ANA) defines assessment as a systemic, dynamic process by which the nurse, through interaction with the client, significant others, and health care providers, collects and analyzes data about the client.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 78

OBJ:2TOP:Nursing process

KEY:Nursing Process Step: AssessmentMSC:NCLEX: N/A

46.Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a ______________.

ANS:

problem

A problem is any health care condition that requires diagnostic, therapeutic, or educational actions.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 81

OBJ: 2 TOP: A problem KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

47.A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes is known as a _____________ ___________.

ANS:

nursing diagnosis

A nursing diagnosis is a type of health problem that can be identified. It is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 81

OBJ:4TOP:Nursing diagnosis

KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A

48.The human responses to health conditions/life processes that exist in an individual, family, or community are known as a(n) _________ _______________ _____________.

ANS:

actual nursing diagnosis

An actual nursing diagnosis is described as the human responses to health conditions/life processes that exist in an individual, family, or community.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 81-83

OBJ:4TOP:Actual nursing diagnosis

KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A

49.Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) __________ __________ ____________.

ANS:

risk nursing diagnosis

A risk nursing diagnosis is defined as the human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 81-83

OBJ:4TOP:Risk nursing diagnosis

KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A

50.Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a _____________ ____________ ____________.

ANS:

wellness nursing diagnosis

A wellness nursing diagnosis is defined as human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 83

OBJ:4TOP:Wellness nursing diagnosis

KEY:Nursing Process Step: DiagnosisMSC:NCLEX: N/A

51.The identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures is known as a _________ _______.

ANS:

medical diagnosis

A medical diagnosis is the identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 83

OBJ: 4 TOP: Medical diagnosis KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

52.A health care system that provides control over health care services for a specific group of individuals in an attempt to control cost is known as ___________ ______________.

ANS:

managed care

Managed care is a health care system that provides control over health care services for a specific group of individuals in attempts to control cost.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 90

OBJ: 6 | 11 TOP: Risk Managed care KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

53.A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases is known as a ___________ ____________.

ANS:

critical pathway

A critical pathway is a multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 90

OBJ: 11 TOP: Clinical pathways KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

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