Nursing process-assessment, diagnosis, planning, implementation and evaluation
Time: 15:00
Which of the following is an example of subjective data?
[a] The patient's blood pressure is 150/92 mmHg.
[b] A 3 cm red rash is observed on the patient's forearm.
[c] The patient states, "I have a sharp pain in my stomach."
[d] The patient's respiratory rate is 22 breaths per minute.
Which statement best describes a nursing diagnosis?
[a] It is the same as a medical diagnosis and is used to identify a disease.
[b] It is a clinical judgment about an individual's response to an actual or potential health problem.
[c] It is a step that only advanced practice nurses can perform.
[d] It describes the patient's medical condition and prognosis.
The nurse develops the following outcome for a patient: "The patient will ambulate 50 feet in the hallway using a walker by post-op day 2." Which element of a SMART goal is best represented?
[a] It is only specific.
[b] It is only achievable.
[c] It is only relevant.
[d] It is specific, measurable, achievable, relevant, and time-bound.
A nurse is administering a patient's scheduled morning medications. Which phase of the nursing process is the nurse performing?
[a] Assessment
[b] Diagnosis
[c] Planning
[d] Implementation
What is the primary purpose of the evaluation phase of the nursing process?
[a] To collect new data about the patient.
[b] To establish a new nursing diagnosis.
[c] To determine if the patient has met the planned goals and outcomes.
[d] To document all the care that was provided.
What is the correct order of the steps in the nursing process?
Gathering information about a patient's health history, vital signs, and physical condition occurs during which step of the nursing process?
[a] Assessment
[b] Planning
[c] Implementation
[d] Evaluation
Which of the following is a correctly written problem-focused (actual) nursing diagnosis?
[a] Risk for Infection.
[b] Diabetes Mellitus.
[c] Acute Pain related to surgical incision as evidenced by a pain rating of 8/10.
[d] Patient will report a pain level of less than 3/10 within one hour.
During the planning phase, the nurse establishes priorities. Which framework is most often used to prioritize nursing diagnoses?
[a] The SBAR communication tool.
[b] The SOAP documentation format.
[c] The hospital's organizational chart.
[d] Maslow's Hierarchy of Needs.
A nurse teaches a patient how to perform self-injection of insulin. This is an example of what type of nursing intervention?
[a] Dependent
[b] Collaborative
[c] Indirect
[d] Independent
After implementing an intervention for pain, the nurse asks the patient to rate their pain on a scale of 0-10. This action is part of which phase?
[a] Diagnosis
[b] Planning
[c] Implementation
[d] Evaluation
In the PES format for a nursing diagnosis, what does the "E" represent?
[a] Evidence
[b] Etiology (the related factors or cause)
[c] Evaluation
[d] Expectation
The nurse observes that a patient is grimacing and guarding their left arm. This is an example of what type of assessment data?
[a] Subjective
[b] Objective
[c] Secondary
[d] Historical
What is the primary purpose of creating a nursing care plan?
[a] To satisfy hospital accreditation requirements.
[b] To provide a bill for insurance companies.
[c] To promote continuity of care and provide individualized, goal-directed nursing care.
[d] To document the patient's medical diagnosis.
Documenting the care provided and the patient's response in the medical record is a critical task within which phase?
[a] Assessment
[b] Diagnosis
[c] Implementation
[d] Evaluation
If evaluation reveals that a patient has not achieved their expected outcome, what is the nurse's next step?
[a] Discharge the patient with follow-up instructions.
[b] Reassess the patient and modify the care plan.
[c] Continue with the same interventions without change.
[d] Ask another nurse to take over the patient's care.
"Risk for Falls as evidenced by history of falls and unsteady gait" is an example of what type of nursing diagnosis?
[a] Problem-focused (actual)
[b] Health promotion
[c] Risk
[d] Syndrome
A physician writes an order for the nurse to administer 2 liters of oxygen via nasal cannula. Carrying out this order is what type of intervention?
[a] Nurse-initiated (independent)
[b] Physician-initiated (dependent)
[c] Collaborative
[d] Optional
The nursing process is described as being "cyclical." What does this mean?
[a] The steps are performed only once per shift.
[b] The steps must be performed in a rigid, linear order.
[c] The findings from one step feed back into the previous steps, creating a continuous loop.
[d] The patient is not involved in the process.
"Readiness for Enhanced Nutrition" is an example of which type of nursing diagnosis?
[a] Risk
[b] Problem-focused (actual)
[c] Health promotion
[d] Medical
Which activity occurs during the assessment phase of the nursing process?
[a] Writing a patient outcome.
[b] Collecting and validating data.
[c] Performing a nursing intervention.
[d] Modifying the care plan.
The nurse, physical therapist, and dietitian meet to develop a coordinated plan of care for a patient. This is an example of an activity in which phase?
[a] Diagnosis
[b] Assessment
[c] Planning
[d] Implementation
A nurse delegates the task of ambulating a stable patient to a nursing assistant. In which phase of the nursing process does this delegation occur?
[a] Evaluation
[b] Assessment
[c] Planning
[d] Implementation
When comparing the patient's current status with their pre-established goals during evaluation, the nurse concludes that the goal has been "met." What does this mean?
[a] The patient's condition has worsened.
[b] The patient has been discharged from the hospital.
[c] The desired patient response has been achieved.
[d] A new nursing diagnosis is needed.
Why is the patient's involvement crucial throughout the entire nursing process?
[a] It is only important during the assessment phase.
[b] It is required by insurance companies.
[c] It shifts the responsibility of care from the nurse to the patient.
[d] It promotes patient-centered care and increases the likelihood of achieving positive outcomes.
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