Chapter 4 The Nursing Process and Decision Making

Chapter 4  The Nursing Process and Decision Making

Complete Chapter Questions And Answers
 

Sample Questions

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. When educating a class of nursing students about the nursing process, the nursing instructor teaches that the nursing process is a
A.
Decision-making framework used by nurses to determine the needs of patients.
B.
Decision-making framework used by social workers when discharging patients.
C.
Decision-making framework used by nursing assistants when caring for patients.
D.
Decision-making framework used by physicians to determine the needs of patients.

____ 2. When reviewing the nursing diagnoses in a student nurse’s written care plan, the nursing instructor recognizes that additional teaching is warranted when the student nurse includes a nursing diagnosis of:
A.
“Pain related to abdominal incision.”
B.
“Altered sensory perception related to surgery.”
C.
“Chronic fatigue syndrome related to poor diet.”
D.
“Altered nutrition related to nausea and vomiting.”

____ 3. The nurse encourages the student nurse to practice using skillful reasoning and logical thought to determine the merits of a belief or action. This approach best describes
A.
Critical thinking.
B.
Sensory overload.
C.
Concrete thinking.
D.
Logical reasoning.

____ 4. The nurse receives an order from the physician for an anticoagulant to be administered to a patient who has a deep vein thrombosis. The nurse recognizes that the patient has a critical international normalized ratio (INR) level. The nurse should
A.
Redraw the INR level.
B.
Call the lab for clarification.
C.
Inform the physician of the INR level.
D.
Administer the anticoagulant in 1 hour.

____ 5. While caring for a newly admitted patient, the nurse interviews the patient to obtain a health history, performs a head-to-toe assessment, and reviews laboratory and diagnostic tests. This step in the nursing process is called
A.
Planning.
B.
Evaluation.
C.
Assessment.
D.
Implementation.

Chapter 4. The Nursing Process and Decision Making
Answer Section

MULTIPLE CHOICE

1. ANS: A

Feedback
A
The nursing process is a decision-making framework used by all nurses to determine the needs of their patients and to decide how to care for them. Chapter Objective: Enumerate the steps of the nursing process.
B
The nursing process is a decision-making framework used by all nurses to determine the needs of their patients and to decide how to care for them.
C
The nursing process is a decision-making framework used by all nurses to determine the needs of their patients and to decide how to care for them.
D
The nursing process is a decision-making framework used by all nurses to determine the needs of their patients and to decide how to care for them.

PTS: 1 REF: Chapter: 4 | Page: 48 OBJ: Chapter Objective: 4-3
KEY: Content Area: Nursing Process | Integrated Process: Nursing Process | Client Need: Health Promotion and Maintenance | Cognitive Level: Application

2. ANS: C

Feedback
A
A care plan is a documented plan for giving patient care and includes physician’s orders, nursing diagnoses, and nursing orders. “Pain” is an example of a nursing diagnosis.
B
A care plan is a documented plan for giving patient care and includes physician’s orders, nursing diagnoses, and nursing orders. “Altered sensory perception” is an example of a nursing diagnosis.
C
A care plan is a documented plan for giving patient care and includes physician’s orders, nursing diagnoses, and nursing orders. Chronic fatigue syndrome is an example of a medical diagnosis. Chapter Objective: Explain how NANDA-I nursing diagnoses are listed.
D
A care plan is a documented plan for giving patient care and includes physician’s orders, nursing diagnoses, and nursing orders. “Altered nutrition” is an example of a nursing diagnosis.

PTS: 1 REF: Chapter: 4 | Page: 48 OBJ: Chapter Objective: 4-8
KEY: Content Area: Care Plans | Integrated Process: Teaching and Learning | Client Need: Health Promotion and Maintenance | Cognitive Level: Application

3. ANS: A

Feedback
A
Critical thinking is using skillful reasoning and logical thought to determine the merits of a belief or action. Chapter Objective: Discuss ways in which critical thinking is used in nursing.
B
Critical thinking is using skillful reasoning and logical thought to determine the merits of a belief or action.
C
Critical thinking is using skillful reasoning and logical thought to determine the merits of a belief or action.
D
Critical thinking is using skillful reasoning and logical thought to determine the merits of a belief or action.

PTS: 1 REF: Chapter: 4 | Page: 48 OBJ: Chapter Objective: 4-2
KEY: Content Area: Critical Thinking | Integrated Process: Nursing Process/Implementation | Client Need: Health Promotion and Maintenance | Cognitive Level: Application

4. ANS: C

Feedback
A
Critical thinking is using skillful reasoning and logical thought to determine the merits of a belief or action. The question provides no information suggesting the initial INR level was incorrect.
B
Critical thinking is using skillful reasoning and logical thought to determine the merits of a belief or action. The nurse needs to speak with the individual who ordered the anticoagulant and the INR level.
C
Critical thinking is using skillful reasoning and logical thought to determine the merits of a belief or action. The nurse needs to speak with the individual (the physician) who ordered the anticoagulant and the INR level. Chapter Objective: Discuss ways in which critical thinking is used in nursing.
D
Critical thinking is using skillful reasoning and logical thought to determine the merits of a belief or action. Administering an anticoagulant when the INR level is already critical does not demonstrate good critical-thinking skills.

PTS: 1 REF: Chapter: 4 | Page: 48 OBJ: Chapter Objective: 4-2
KEY: Content Area: Pharmacology | Category of Health Alteration: Critical INR Level | Integrated Process: Nursing Process/Implementation | Client Need: Safe and Effective Care Environment | Cognitive Level: Analysis

5. ANS: C

Feedback
A
Planning is the process of determining priorities and what nursing actions should be performed to help resolve or manage each patient problem. In addition, the nurse determines expected outcomes for the patient to meet for the nursing diagnosis to be resolved, as well as a realistic time frame for that to occur. The nurse then decides on appropriate interventions to resolve each patient problem, or nursing diagnosis.
B
Evaluation is performed when the nurse reflects on the interventions that he or she has performed and decides if they have brought the patient closer to achieving the goals and outcomes set in the planning step. If not, the nurse then revises and changes the interventions and perhaps the goals to better fit the needs of the patient.
C
Assessment is the gathering of information through signs and symptoms, patient history, and objective findings. Just as a physician gathers information by performing a physical exam and a patient history, the nurse gathers information about the patient through asking questions (interviewing), performing a head-to-toe assessment, and reviewing laboratory and diagnostic tests. Chapter Objective: Enumerate the steps of the nursing process.
D
Implementation is the process of taking actions to resolve the patient’s problems, the nursing diagnoses. These actions are also called interventions. When the nurse performs these interventions, it is called implementation. The nurse implements the plan to help resolve the patient’s problems.

PTS: 1 REF: Chapter: 4 | Page: 49 OBJ: Chapter Objective: 4-3
KEY: Content Area: Nursing Process | Integrated Process: Nursing Process/Assessment | Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis