Chapter 08 Nursing Process

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Chapter 08  Nursing Process

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

MULTIPLE CHOICE

1. A nurse is collecting data on a patient he is admitting into hospice care. He collects data from both the patient and the family so that he has a clear picture of the patient status. Which step of the nursing process is the nurse currently involved in?
A.
Assessment
B.
Implementation
C.
Evaluation
D.
Diagnosing

ANS: A
Assessment is the deliberate and systematic collection of data about a patient. The data will reveal a patient’s current and past health status, functional status, and present and past coping patterns (Carpenito-Moyet, 2008). Assessment requires a nurse to apply critical thinking so that in the end, the nurse believes he or she has a clear picture of a patient’s condition.

PTS: 1 DIF: Cognitive Level: Application REF: 106
OBJ: Describe each step of the nursing process
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment

2. This is a registered nurse’s first day back to work since she has been on vacation. She is admitting a patient to the unit. She asks the patient about his health history. Which of the following components of the nursing process is she engaged in?
A.
Evaluation
B.
Diagnosis
C.
Assessment
D.
Planning

ANS: C
An assessment database includes a patient’s comprehensive health history, which includes information about a patient’s physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system. The database also includes physical examination findings and a summary of results from laboratory and diagnostic testing.

PTS: 1 DIF: Cognitive Level: Application REF: 106
OBJ: Describe each step of the nursing process
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment

3. Harry, a registered nurse, has responded to a call light in a patient’s room. Mr. Greene is a postoperative patient who is continuing to have incisional pain. As part of Harry’s assessment, he notes that Mr. Greene is grimacing when he changes position. Mr. Greene’s grimace can be useful in Harry’s assessment and can be described as which of the following?
A.
Cue
B.
Inference
C.
Diagnosis
D.
Health pattern

ANS: A
A cue is information that a nurse obtains through use of the senses.

PTS: 1 DIF: Cognitive Level: Application REF: 106
OBJ: Discuss approaches to data collection in nursing assessment
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment

4. Mr. Greene, the postoperative patient, has denied the need for pain medication. Harry, his nurse, has assessed Mr. Greene and has noted that he describes his pain as an “1” on a 0 to 10 scale. Harry notes that Mr. Greene grimaces when he changes position and guards his incision. Harry believes that Mr. Greene is experiencing pain based on the information he gathered in his assessment. What is this phenomena known as?
A.
Cue
B.
Inference
C.
Diagnosis
D.
Health pattern

ANS: B
An inference is a nurse’s judgment or interpretation of a cue.

PTS: 1 DIF: Cognitive Level: Application REF: 106
OBJ: Discuss approaches to data collection in nursing assessment
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment

5. A student nurse is collecting data during the assessment of her patient. During the assessment, she collects both subjective and objective data. Which of the following would be considered subjective data?
A.
Heart rate of 96
B.
Incisional erythema
C.
Emesis of 150 mL
D.
Pain rating of 5

ANS: D
Subjective data are patients’ verbal descriptions of their health problems. Only patients provide subjective data.

PTS: 1 DIF: Cognitive Level: Analysis REF: 108
OBJ: Differentiate between subjective and objective data
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment

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