12: Chapter The Nursing Process and Critical Thinking
MULTIPLE CHOICE 1. The primary purpose of incorporating the nursing process into the care of patients is to: 1. establish a basis of communication with other nursing staff. 2. maintain compliance with existing national nursing standards. 3. provide structure and organization to the delivery of medical care to the patient. 4. address current health issues, as well as health maintenance and rehabilitation. ANS: 4 The goal of the nursing process is to alleviate, minimize, or prevent actual or potential health problems and direct nursing care, not medical care. PTS: 1 DIF: Cognitive Level: Knowledge REF: 143 OBJ: 1 TOP: Purpose of the Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. The five steps of the nursing process, in the correct order, are: 1. data collection, nursing diagnosis, planning, intervention, and evaluation. 2. assessment, planning, documentation, intervention, and evaluation. 3. data collection, diagnosis, assessment, planning, and evaluation. 4. history, physical, diagnosis, intervention, and evaluation. ANS: 1 The nursing process is a systematic method of providing care to patients. Each phase is dependent on the other phases. PTS: 1 DIF: Cognitive Level: Knowledge REF: 143 OBJ: 1 TOP: The Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. The nursing process is based on: 1. the medical diagnosis of the patient. 2. identified physiological and psychological needs of the patient. 3. standards of nursing care provided by the American Nurses Association. 4. orders of the primary care provider. ANS: 2 The nursing process assesses the needs of the patient to establish goals and carry out nursing implementations. PTS: 1 DIF: Cognitive Level: Knowledge REF: 148 OBJ: 1 TOP: The Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. The nursing care plan is initiated by the: 1. primary care provider. 2. registered nurse.
3. licensed practical nurse. 4. nurse manager. ANS: 2 The LPN/LVN may contribute to the nursing care plan, but the care plan itself must be initiated by a registered nurse. PTS: 1 DIF: Cognitive Level: Knowledge REF: 148-149 OBJ: 2 TOP: Initiation of the Nursing Care Plan KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. When a patient plan of care has been written, it: 1. is continually reviewed and evaluated. 2. must be reviewed by the primary caregiver. 3. remains in effect until the patient is discharged. 4. can only be changed by the initiating nurse. ANS: 1 The care plan should reflect the current needs of the patient. PTS: 1 DIF: Cognitive Level: Knowledge REF: 143 OBJ: 2 TOP: Nursing Care Plan KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 6. The nurse uses palpation for the purpose of: 1. determining areas of tenderness. 2. differentiating between fluid- and air-filled organs. 3. hearing sounds produced by the body. 4. a systematic approach of physical assessment. ANS: 1 Palpation is a method of touching the patient to obtain information about symptoms and signs such as skin temperature, condition, and pain. PTS: 1 DIF: Cognitive Level: Knowledge REF: 146 OBJ: 2 TOP: Palpation KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 7. The patient complains of a headache. This data would be classified as: 1. subjective. 2. objective. 3. pain assessment. 4. undifferentiated data. ANS: 1 Subjective data are data reported by the patient or family. They are data that cannot be observed. PTS: 1 DIF: Cognitive Level: Comprehension REF: 144 OBJ: 3 TOP: Subjective Data KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
8. The nurse notes the previous 24-hour urine output was 950 mL, well below the normal of 1500 mL. An effective nursing order to remedy the impending dehydration would be to: 1. offer more fluids daily. 2. offer 8 ounces of juice or tea at 0800 (8 AM), 1200 (12 noon), 1600 (4 PM), and 2000 (8 PM). 3. request extra fluid on a diet tray from the kitchen. 4. place a large water pitcher at the bedside during each shift. ANS: 2 The statement is clear and measurable and relates directly to the potential of dehydration. The other options are vague and have no measurement criteria. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Analysis 2 TOP: Nursing Implementation Nursing Process Step: Implementation NCLEX: Health Promotion and Maintenance REF: 150
9. When percussing the patients abdomen, the note that the nurse anticipates is: 1. flat. 2. dull. 3. tympanic. 4. resonant. ANS: 3 Tympanic notes are anticipated over an air-filled organ such as the stomach. PTS: 1 DIF: Cognitive Level: Application REF: 146 OBJ: 1 TOP: Percussion KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. Which of the following documentation entries is an example of objective data? 1. An area of erythema to the upper right extremity approximately 1 by 4 inches 2. Complaint of pain in the RLQ of the abdomen rated 5 on pain scale of 1 to 10 3. Family states that the patient does not sleep at night and wanders about the house 4. Assessment reveals past history of drug abuse ANS: 1 Objective data are data that are observable and measurable. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 4 TOP: Data Collection Nursing Process Step: Assessment NCLEX: Health Promotion and Maintenance REF: 144
11. When the postsurgical patient complains of shortness of breath, the nurse should immediately: 1. raise the head of the bed to 30 degrees. 2. take vital signs. 3. perform a focused assessment.
4. inform the charge nurse. ANS: 1 Although all these options will be eventually performed, the initial implementation should be to raise the head of the bed to ease breathing, perform a focused assessment with vital signs and O2 concentration, and then inform the charge nurse about the patients symptoms and your assessment findings. PTS: 1 DIF: Cognitive Level: Analysis REF: 149-150 OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. An example of a complete nursing diagnosis is: 1. peripheral neurovascular dysfunction. 2. peripheral neurovascular dysfunction exhibited by patient complaint. 3. peripheral neurovascular dysfunction related to decreased sensation, exhibited by the statement that My feet are tingling. 4. peripheral neurovascular dysfunction exhibited by patient statement. ANS: 3 A complete nursing diagnosis includes diagnosis, related to, and exhibited by problem, cause, and signs/symptoms (PES). PTS: 1 DIF: Cognitive Level: Application OBJ: 2 TOP: Nursing Diagnosis KEY: Nursing Process Step: Nursing Diagnosis REF: 148 MSC: NCLEX: N/A
13. The nurse assisting with prioritizing nursing diagnoses would select which of the following as the highest priority? 1. Impaired adjustment 2. Acute pain 3. Risk for imbalanced body temperature 4. Ineffective airway clearance ANS: 4 Without a clear airway, there is no need for the other diagnoses. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Analysis 2 TOP: Nursing Diagnosis Nursing Process Step: Planning NCLEX: Health Promotion and Maintenance REF: 149-150
14. The best example of a nursing order is: 1. perform deep breathing exercises twice daily at 10 AM and 2 PM. 2. administer Tylenol every 4 hours as needed for headache. 3. skin integrity, risk for impairment. 4. the patient will perform quad setting exercises frequently. ANS: 1 Nursing orders should include a specific description of what, where, when, how much, how long, and how the order should be carried out.
PTS: 1 DIF: Cognitive Level: Analysis REF: 150 OBJ: 3 TOP: Nursing Orders KEY: Nursing Step: Process Planning MSC: NCLEX: N/A 15. Nursing interventions classifications (NIC): 1. are mandated by NANDA as interventions that are to be used for all patients. 2. is a list of currently approved nursing goals. 3. are instituted based on individual patient needs. 4. are guidelines for goal setting and documentation of nursing care given to patients. ANS: 3 NIC is a standardized list of nursing implementations divided into seven domains. The nurse selects those that pertain to the patient, and implements them. PTS: 1 DIF: Cognitive Level: Knowledge REF: 150 OBJ: 2 TOP: Nursing Interventions KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 16. The nurse is aware of the goal of Patient will eat at least 50% of all meals. The nurse has observed the patient eating over 50% of all meals for 2 days. The evaluation statement should read: 1. ate well for all meals. 2. resolved: goal met. 3. goal met: patient ate 50% of all meals on 7/12 and 7/13. 4. ate 50% of meals. ANS: 3 The evaluation statement should reflect the actual outcome compared to the expected outcome, with the qualifying statement of goal met, goal not met, goal partially met. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Application 2 TOP: Nursing Diagnosis: Evaluation Nursing Process Step: Evaluation NCLEX: Health Promotion and Maintenance REF: 150
17. Data collection consists of: 1. information supplied by patient and family. 2. health history, physical assessment, and documentation. 3. health history and physical assessment. 4. assessment, patient records, and diagnostic tests. ANS: 4 Diagnostic tests supply general information that can be helpful in identifying general areas in which a patient might have a health care problem. Patient records provide valuable information regarding the past medical history and present illness. Physical assessment can provide information concerning the patients current needs. PTS: 1 OBJ: 1 DIF: Cognitive Level: Application TOP: Data Collection REF: 144
KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
18. The patient will maintain an adequate nutritional state without nausea or vomiting is an example of: 1. a nursing intervention. 2. the nursing process. 3. a nursing diagnosis. 4. a nursing goal. ANS: 4 Goals should be stated in terms of observable patient outcomes. PTS: OBJ: KEY: MSC: 1 DIF: Cognitive Level: Analysis 2 TOP: Nursing Goals Nursing Process Step: Planning NCLEX: Health Promotion and Maintenance REF: 149
19. Nursing outcome classification (NOC) is a method of classification of: 1. the nursing process. 2. the nursing care plan. 3. nursing goals. 4. nursing intervention outcomes. ANS: 4 NOC is a new classification system for outcomes that are amenable to nursing implementations. PTS: 1 DIF: Cognitive Level: Knowledge REF: 150 OBJ: 1 TOP: Nursing Outcome Classification (NOC) KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 20. Standardized care plans are: 1. clinical pathways. 2. evaluation tools. 3. outcome criteria. 4. nursing interventionbased. ANS: 1 Clinical pathways are standard care plans developed to set daily care priorities, schedule achievement outcomes, and reduce length of hospital stay. PTS: 1 DIF: Cognitive Level: Comprehension REF: 151 OBJ: 3 TOP: Clinical Pathways KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. Documentation should include: 1. objective and subjective data. 2. observations made by other nursing staff. 3. information that is accurate and complete. 4. incidence reports.
ANS: 3 Documentation should be clear, concise, complete, and accurate. PTS: 1 DIF: Cognitive Level: Application REF: 155 OBJ: 3 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 22. The most effective documentation is: 1. 7/27 945 AM Pt. vomited, Pt. looked better after episode. A. Nurse, LPN 2. 7/27 945 AM Pt. vomited large amount. Reduced nausea. 3. 7/27 945 AM Pt. reported less nausea after vomiting. A. Nurse, LPN 4. 7/27 0945 AM Pt. vomited 200 mL of partially digested food. Pt. states nausea diminished. A. Nurse, LPN. ANS: 4 Documentation should be completed immediately after care is given, never before care. It should be timed and dated, ending with the signature of the nurse performing the care or making the observation. Charting should be objective and describe only what is seen, heard, felt, or smelled. PTS: 1 DIF: Cognitive Level: Analysis REF: 155 OBJ: 3 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 23. Problem-oriented medical records (POMRs): 1. focus on patient response to treatment. 2. is source-oriented charting. 3. reflect the patients current problems. 4. focus on medical diagnosis. ANS: 3 POMR is a method of keeping records that focuses on patient problems rather than on medical diagnosis. It is an excellent form of communication among various disciplines that are providing care. PTS: 1 DIF: Cognitive Level: Application REF: 155-156 OBJ: 3 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 24. Characteristics of critical thinking include: 1. interpretation, analysis, and evaluation. 2. patient-centered criteria and problem solving. 3. realistic outcomes and frequent evaluation. 4. data gathering and assessment. ANS: 1
Critical thinking is reflective and reasonable thinking focused on deciding what to do. Characteristics include interpretation, analysis, evaluation, inference, explanation, and self-regulation. PTS: 1 DIF: Cognitive Level: Analysis REF: 157 OBJ: 6 TOP: Critical Thinking KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 25. Critical thinking is an integral part of the nursing process because it: 1. promotes flexibility and individualized care. 2. incorporates decision making. 3. includes the patient in part of the nursing process. 4. provides guidelines of care. ANS: 1 The nursing process is a sequence of steps that requires critical thinking to provide sound, individualized patient care. Critical thinking makes the nursing process accurate, scientifically sound, appropriate, flexible, and individualized. PTS: 1 DIF: Cognitive Level: Analysis REF: 158 OBJ: 4 TOP: Critical Thinking and the Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 1. The nurse auscultating the patients chest will (select all that apply): 1. use the diaphragm for assessing breath sounds. 2. use the bell for assessing murmurs. 3. apply earpieces pointing toward the ears. 4. wet the chest hair with a cloth. 5. press the diaphragm very firmly against the chest wall. ANS: 1, 2, 4 A diaphragm is used to hear high-pitched sounds and a bell is used to hear low-pitched sounds. Chest hair is moistened to diminish cracking sounds, which could be misleading. The earpieces should be pointing toward the nose. The use of the diaphragm requires a light pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: 146-147 OBJ: 1 TOP: Auscultation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A COMPLETION 1. In PIE documentation, a type of POMR (problem-oriented medical records), the acronym PIE stands for ____________________, ____________________ and ____________________. ANS: Problem, intervention, evaluation
PTS: 1 DIF: Cognitive Level: Comprehension REF: 157 OBJ: 4 TOP: PIE Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. Examine this goal statement: Patient will walk in the hall unassisted. The two components for a correctly stated goal statement that are missing from the example above are the descriptors for ____________________ and ____________________. ANS: Frequency, time duration PTS: 1 DIF: Cognitive Level: Analysis REF: 150 OBJ: 1 TOP: Goal Statements KEY: Nursing Process Step: N/A MSC: NCLEX: N/A