NR 226 Chapter 16: Nursing Assessment Potter et al.: Fundamentals of Nursing, 9th Edition

1. The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? a. Completes a comprehensive database b. Identifies pertinent nursing diagnoses c. Intervenes based on priorities of patient care d. Determines whether outcomes have been achieved ANS: A The assessment phase of the nursing process involves data collection to complete a thorough patient database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The nurse carries out interventions during the implementation phase (fourth phase), and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process. DIF: Apply (application) REF: 210 OBJ: Discuss the relationship between critical thinking and nursing assessment. TOP: Assessment MSC: Health Promotion and Maintenance 2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? a. Complete the questions in chronological order. b. Focus on the patient’s presenting situation. c. Make accurate interpretations of the data. d. Conduct an observational overview. ANS: B A problem-oriented approach focuses on the patient’s current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection. DIF: Apply (application) REF: 210 | 213 OBJ: Describe the methods of data collection. TOP: Assessment MSC: Health Promotion and Maintenance 3. After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make?