NR 224 Fundamentals of Nursing – Exam 1
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Answers & Detailed Rationales |
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What is the first component required for decision making according to
the critical thinking model?
Correct answer- scientific knowledge base
Expert Rationale
The critical thinking model in nursing identifies the scientific knowledge
base as the foundational first component required for effective clinical
decision making. Before a nurse can analyze data, prioritize hypotheses, or
,generate solutions, they must possess a solid foundation of biomedical
and nursing science. This includes knowledge of anatomy, physiology,
pharmacology, pathophysiology, and nursing theory. Without this baseline,
the nurse cannot accurately interpret patient data, recognize deviations
from normal, or select appropriate interventions. The scientific knowledge
base serves as the cognitive "toolbox" from which the nurse draws
evidence-based information to inform every subsequent step of the critical
thinking process, including assessment, diagnosis, planning,
implementation, and evaluation. It is this knowledge that allows the nurse
to move beyond task-oriented care and engage in deliberate, reasoned
clinical judgment.
DIF: Cognitive Level: Remember (Knowledge) TOP: Nursing Process:
Assessment MSC: NCLEX: Safe and Effective Care Environment
Completing a comprehensive database is done during which phase of the
nursing process?
Correct answer- assessment
Expert Rationale
The nursing process is a systematic, five-step framework that guides
patient-centered care. The first phase, assessment, involves the systematic
collection, organization, validation, and documentation of comprehensive
patient data. This includes subjective data (what the patient reports) and
objective data (what the nurse observes, measures, or gathers through
physical examination, diagnostic tests, and review of medical records).
Completing a comprehensive database during this initial phase is essential
because it establishes the baseline from which all subsequent nursing
judgments and actions are derived. Without a thorough and accurate
assessment, the nurse cannot identify actual or potential health problems,
formulate accurate nursing diagnoses, develop individualized care plans,
,implement appropriate interventions, or evaluate outcomes effectively.
The quality of the entire nursing process hinges directly on the
completeness and accuracy of the initial assessment data.
DIF: Cognitive Level: Remember (Knowledge) TOP: Nursing Process:
Assessment MSC: NCLEX: Safe and Effective Care Environment
After data collection and analysis to identify patient problems, what is
the next phase of the nursing process?
Correct answer- Diagnosis
(data collection AND analysis occur during the Assessment phase)
Expert Rationale
The nursing process follows a logical, sequential progression. After the
nurse completes the assessment phase — which includes both data
collection and data analysis — the next phase is diagnosis. During the
diagnosis phase, the nurse synthesizes and interprets the analyzed data to
identify actual or potential patient health problems. This is where clinical
judgment is applied to formulate nursing diagnoses, which are
standardized clinical statements that describe patient responses to actual
or potential health conditions. These diagnoses provide the foundation for
selecting appropriate nursing interventions. It is important to note that
while data analysis occurs within the assessment phase, the formal
identification and labeling of patient problems occurs in the diagnosis
phase. This clear distinction ensures that critical thinking is applied
systematically, preventing premature closure or jumping to conclusions
before all relevant data have been fully considered.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process:
Diagnosis MSC: NCLEX: Safe and Effective Care Environment
, Read the following nursing diagnosis. Which part(s) identifies the
defining characteristic(s)?
Impaired gas exchange r/t lack of oxygen flow aeb pt exhibiting shortness
of breath & nasal cannula out of pt's nose
Correct answer- Shortness of breath & nasal cannula out of nose
Expert Rationale
In a properly written nursing diagnosis, the PES format is used: Problem
(P), Etiology (E), and Signs/Symptoms (S). The "defining characteristics" are
the clinical cues, signs, and symptoms that support the presence of the
nursing diagnosis. These are the observable, measurable, or subjective
indicators that validate the existence of the problem. In the given
diagnosis, "Impaired gas exchange" is the problem (P), "lack of oxygen
flow" is the etiology or related factor (E), and the "aeb" (as evidenced by)
portion introduces the defining characteristics (S). The defining
characteristics are specifically the patient's shortness of breath and the
dislodged nasal cannula, as these are the clinical manifestations that
provide evidence for the diagnosis. Recognizing defining characteristics is
essential because they guide the nurse in selecting appropriate
interventions and in later evaluating whether the problem has been
resolved or improved.
DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
Give an appropriate goal for this nursing diagnosis: Acute pain r/t
surgical site infection aeb pt rates pain 9/10 continuously
Correct answer- (could be a number of responses but goals should be
written/stated in a format such as):
Pt will _______________ by ________________
For example, pt will rate pain less than 4/10 on pain scale by 1200.
Study Pack | Verified Questions, Correct
Answers & Detailed Rationales |
Chamberlain| A+ Exam Review
What is the first component required for decision making according to
the critical thinking model?
Correct answer- scientific knowledge base
Expert Rationale
The critical thinking model in nursing identifies the scientific knowledge
base as the foundational first component required for effective clinical
decision making. Before a nurse can analyze data, prioritize hypotheses, or
,generate solutions, they must possess a solid foundation of biomedical
and nursing science. This includes knowledge of anatomy, physiology,
pharmacology, pathophysiology, and nursing theory. Without this baseline,
the nurse cannot accurately interpret patient data, recognize deviations
from normal, or select appropriate interventions. The scientific knowledge
base serves as the cognitive "toolbox" from which the nurse draws
evidence-based information to inform every subsequent step of the critical
thinking process, including assessment, diagnosis, planning,
implementation, and evaluation. It is this knowledge that allows the nurse
to move beyond task-oriented care and engage in deliberate, reasoned
clinical judgment.
DIF: Cognitive Level: Remember (Knowledge) TOP: Nursing Process:
Assessment MSC: NCLEX: Safe and Effective Care Environment
Completing a comprehensive database is done during which phase of the
nursing process?
Correct answer- assessment
Expert Rationale
The nursing process is a systematic, five-step framework that guides
patient-centered care. The first phase, assessment, involves the systematic
collection, organization, validation, and documentation of comprehensive
patient data. This includes subjective data (what the patient reports) and
objective data (what the nurse observes, measures, or gathers through
physical examination, diagnostic tests, and review of medical records).
Completing a comprehensive database during this initial phase is essential
because it establishes the baseline from which all subsequent nursing
judgments and actions are derived. Without a thorough and accurate
assessment, the nurse cannot identify actual or potential health problems,
formulate accurate nursing diagnoses, develop individualized care plans,
,implement appropriate interventions, or evaluate outcomes effectively.
The quality of the entire nursing process hinges directly on the
completeness and accuracy of the initial assessment data.
DIF: Cognitive Level: Remember (Knowledge) TOP: Nursing Process:
Assessment MSC: NCLEX: Safe and Effective Care Environment
After data collection and analysis to identify patient problems, what is
the next phase of the nursing process?
Correct answer- Diagnosis
(data collection AND analysis occur during the Assessment phase)
Expert Rationale
The nursing process follows a logical, sequential progression. After the
nurse completes the assessment phase — which includes both data
collection and data analysis — the next phase is diagnosis. During the
diagnosis phase, the nurse synthesizes and interprets the analyzed data to
identify actual or potential patient health problems. This is where clinical
judgment is applied to formulate nursing diagnoses, which are
standardized clinical statements that describe patient responses to actual
or potential health conditions. These diagnoses provide the foundation for
selecting appropriate nursing interventions. It is important to note that
while data analysis occurs within the assessment phase, the formal
identification and labeling of patient problems occurs in the diagnosis
phase. This clear distinction ensures that critical thinking is applied
systematically, preventing premature closure or jumping to conclusions
before all relevant data have been fully considered.
DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process:
Diagnosis MSC: NCLEX: Safe and Effective Care Environment
, Read the following nursing diagnosis. Which part(s) identifies the
defining characteristic(s)?
Impaired gas exchange r/t lack of oxygen flow aeb pt exhibiting shortness
of breath & nasal cannula out of pt's nose
Correct answer- Shortness of breath & nasal cannula out of nose
Expert Rationale
In a properly written nursing diagnosis, the PES format is used: Problem
(P), Etiology (E), and Signs/Symptoms (S). The "defining characteristics" are
the clinical cues, signs, and symptoms that support the presence of the
nursing diagnosis. These are the observable, measurable, or subjective
indicators that validate the existence of the problem. In the given
diagnosis, "Impaired gas exchange" is the problem (P), "lack of oxygen
flow" is the etiology or related factor (E), and the "aeb" (as evidenced by)
portion introduces the defining characteristics (S). The defining
characteristics are specifically the patient's shortness of breath and the
dislodged nasal cannula, as these are the clinical manifestations that
provide evidence for the diagnosis. Recognizing defining characteristics is
essential because they guide the nurse in selecting appropriate
interventions and in later evaluating whether the problem has been
resolved or improved.
DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
Give an appropriate goal for this nursing diagnosis: Acute pain r/t
surgical site infection aeb pt rates pain 9/10 continuously
Correct answer- (could be a number of responses but goals should be
written/stated in a format such as):
Pt will _______________ by ________________
For example, pt will rate pain less than 4/10 on pain scale by 1200.
