Fundamentals of Nursing Exam 1 TB
Chapters 9, 13, 14, 15, 27, 28, 29, 31, 32, 36, and 37
Chapter 09: Nursing Process My Nursing Test Banks
Chapter 09: Nursing Process
Potter: Essentials for Nursing Practice, 8th Edition
MULTIPLE CHOICE
1.A nurse is collecting data on a patient who is being admitted into hospice care. The nurse
collects data from both the patient and the family so that a clear picture of the patient status is
obtained. The nurse is currently involved in which step of the nursing process?
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 patients current and past health status, functional status, and present and past coping
patterns. A nursing diagnosis is a clinical judgment about individual, family, or community
responses to actual and potential health problems or life processes that the nurse is licensed and
competent to treat. Implementation is the performance of nursing interventions necessary for
achieving the goals and expected outcomes of nursing care. Evaluation is crucial to deciding
whether, after interventions have been delivered, a patients condition or well-being improves.
PTS:1DIF:Cognitive Level: Applying (Application)
REF:124OBJescribe each step of the nursing process.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
2.The nurse is admitting a patient to the unit and asks the patient about the health history. The
nurse is engaged in which component of the nursing process?
a. Evaluation
b. Diagnosis
, c. Assessment
d. Planning
ANS: C
The nurse is in the assessment phase. An assessment database includes a patients comprehensive
health history, which includes information about a patients 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. A nursing diagnosis is a clinical judgment about
individual, family, or community responses to actual and potential health problems or life
processes that the nurse is licensed and competent to treat. Evaluation is crucial to deciding
whether, after interventions have been delivered, a patients condition or well-being improves.
Planning involves setting priorities, identifying patient-centered goals and expected outcomes,
and prescribing nursing interventions.
PTS:1DIF:Cognitive Level: Applying (Application)
REF: 124 OBJ: Discuss approaches to data collection in nursing assessment.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
3.A postoperative patient is continuing to have incisional pain. As part of the nurses assessment,
the nurse notes that the patient is grimacing when he or she changes position. The patients
grimace can be useful in the assessment and can be described as which of the following?
a. Cue
b. Inference
c. Diagnosis
d. Health pattern
ANS: A
Grimacing is a cue. A cue is information that a nurse obtains through use of the senses. An
inference is your judgment or interpretation of these cues. Gordons functional health patterns are
a type of database format to obtain a comprehensive assessment. A nursing diagnosis is a clinical
judgment about individual, family, or community responses to actual and potential health
problems or life processes that the nurse is licensed and competent to treat.
PTS:1DIF:Cognitive Level: Applying (Application)
REF: 125 OBJ: Explain the type of conclusions that result from data analysis.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
,4.A postoperative patient has denied the need for pain medication. The nurse has noted that the
patient describes the pain as a 1 on a 0 to 10 scale. The nurse also notes that the patient grimaces
when he or she changes position and guards the incision. The nurse believes that the patient is
experiencing pain based on the information gathered in the assessment. What is this phenomenon
known as?
a. Cue
b. Inference
c. Diagnosis
d. Health pattern
ANS: B
The nurse made a judgment, which is an inference, that the patient is experiencing pain. An
inference is a nurses judgment or interpretation of a cue. A cue is information that you obtain
through use of the senses. Gordons functional health patterns are a type of database format to
obtain a comprehensive assessment. A nursing diagnosis is a clinical judgment about individual,
family, or community responses to actual and potential health problems or life processes that the
nurse is licensed and competent to treat such as impaired tissue perfusion.
PTS:1DIF:Cognitive Level: Applying (Application)
REF: 125 OBJ: Explain the type of conclusions that result from data analysis.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
5.A nurse is collecting data during the assessment of a patient. During the assessment, the nurse
collects both subjective and objective data. Which information should the nurse consider as
subjective data?
a. Heart rate of 96
b. Incisional erythema
c. Emesis of 150 mL
d. Sharp, burning pain
ANS: D
Sharp, burning pain is subjective. Subjective data are patients verbal descriptions of their health
problems. Only patients provide subjective data. Heart rate, incisions, and emesis are all
objective data. Objective data are observations or measurements of a patients health status.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
, REF: 126 OBJ: Differentiate between subjective and objective data.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
6.The nurse has just completed an assessment on a patient with a fractured right femur. Which
data will the nurse categorize as objective?
a. The patients toes of right foot are warm and pink.
b. The patient reports a dull ache in the right hip.
c. The patient says feels tired all the time.
d. The patient is concerned about insurance coverage.
ANS: A
Toes pink and warm are objective data. Objective data are observations or measurements of a
patients health status. Subjective data are patients verbal descriptions of their health problems.
Only patients provide subjective data.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF: 126 OBJ: Differentiate between subjective and objective data.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
7.A student nurse is responsible for assessing a patient, who is abrupt and requests that the
assessment be done later by a nurse. As the student nurse charts the interaction, which statement
is the best way to document what happened?
a. Appears to be in pain as evidenced by grouchy behavior
b. Behavior is inappropriate, requests registered nurse do the assessment
c. States, I want a registered nurse to do my assessment
d. Is grumpy, registered nurse notified
ANS: C
When a nurse collects objective data, he or she should apply critical thinking intellectual
standards (e.g., clear, precise, and consistent). Nurses do not include personal interpretive
statements. The timely, thorough, and accurate communication of facts is necessary to ensure
continuity and appropriateness of patient care. If you do not report or record an assessment
finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient.
Grouchy, inappropriate, and grumpy are personal interpretive statements and should be avoided.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
Chapters 9, 13, 14, 15, 27, 28, 29, 31, 32, 36, and 37
Chapter 09: Nursing Process My Nursing Test Banks
Chapter 09: Nursing Process
Potter: Essentials for Nursing Practice, 8th Edition
MULTIPLE CHOICE
1.A nurse is collecting data on a patient who is being admitted into hospice care. The nurse
collects data from both the patient and the family so that a clear picture of the patient status is
obtained. The nurse is currently involved in which step of the nursing process?
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 patients current and past health status, functional status, and present and past coping
patterns. A nursing diagnosis is a clinical judgment about individual, family, or community
responses to actual and potential health problems or life processes that the nurse is licensed and
competent to treat. Implementation is the performance of nursing interventions necessary for
achieving the goals and expected outcomes of nursing care. Evaluation is crucial to deciding
whether, after interventions have been delivered, a patients condition or well-being improves.
PTS:1DIF:Cognitive Level: Applying (Application)
REF:124OBJescribe each step of the nursing process.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
2.The nurse is admitting a patient to the unit and asks the patient about the health history. The
nurse is engaged in which component of the nursing process?
a. Evaluation
b. Diagnosis
, c. Assessment
d. Planning
ANS: C
The nurse is in the assessment phase. An assessment database includes a patients comprehensive
health history, which includes information about a patients 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. A nursing diagnosis is a clinical judgment about
individual, family, or community responses to actual and potential health problems or life
processes that the nurse is licensed and competent to treat. Evaluation is crucial to deciding
whether, after interventions have been delivered, a patients condition or well-being improves.
Planning involves setting priorities, identifying patient-centered goals and expected outcomes,
and prescribing nursing interventions.
PTS:1DIF:Cognitive Level: Applying (Application)
REF: 124 OBJ: Discuss approaches to data collection in nursing assessment.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
3.A postoperative patient is continuing to have incisional pain. As part of the nurses assessment,
the nurse notes that the patient is grimacing when he or she changes position. The patients
grimace can be useful in the assessment and can be described as which of the following?
a. Cue
b. Inference
c. Diagnosis
d. Health pattern
ANS: A
Grimacing is a cue. A cue is information that a nurse obtains through use of the senses. An
inference is your judgment or interpretation of these cues. Gordons functional health patterns are
a type of database format to obtain a comprehensive assessment. A nursing diagnosis is a clinical
judgment about individual, family, or community responses to actual and potential health
problems or life processes that the nurse is licensed and competent to treat.
PTS:1DIF:Cognitive Level: Applying (Application)
REF: 125 OBJ: Explain the type of conclusions that result from data analysis.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
,4.A postoperative patient has denied the need for pain medication. The nurse has noted that the
patient describes the pain as a 1 on a 0 to 10 scale. The nurse also notes that the patient grimaces
when he or she changes position and guards the incision. The nurse believes that the patient is
experiencing pain based on the information gathered in the assessment. What is this phenomenon
known as?
a. Cue
b. Inference
c. Diagnosis
d. Health pattern
ANS: B
The nurse made a judgment, which is an inference, that the patient is experiencing pain. An
inference is a nurses judgment or interpretation of a cue. A cue is information that you obtain
through use of the senses. Gordons functional health patterns are a type of database format to
obtain a comprehensive assessment. A nursing diagnosis is a clinical judgment about individual,
family, or community responses to actual and potential health problems or life processes that the
nurse is licensed and competent to treat such as impaired tissue perfusion.
PTS:1DIF:Cognitive Level: Applying (Application)
REF: 125 OBJ: Explain the type of conclusions that result from data analysis.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
5.A nurse is collecting data during the assessment of a patient. During the assessment, the nurse
collects both subjective and objective data. Which information should the nurse consider as
subjective data?
a. Heart rate of 96
b. Incisional erythema
c. Emesis of 150 mL
d. Sharp, burning pain
ANS: D
Sharp, burning pain is subjective. Subjective data are patients verbal descriptions of their health
problems. Only patients provide subjective data. Heart rate, incisions, and emesis are all
objective data. Objective data are observations or measurements of a patients health status.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
, REF: 126 OBJ: Differentiate between subjective and objective data.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
6.The nurse has just completed an assessment on a patient with a fractured right femur. Which
data will the nurse categorize as objective?
a. The patients toes of right foot are warm and pink.
b. The patient reports a dull ache in the right hip.
c. The patient says feels tired all the time.
d. The patient is concerned about insurance coverage.
ANS: A
Toes pink and warm are objective data. Objective data are observations or measurements of a
patients health status. Subjective data are patients verbal descriptions of their health problems.
Only patients provide subjective data.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
REF: 126 OBJ: Differentiate between subjective and objective data.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
7.A student nurse is responsible for assessing a patient, who is abrupt and requests that the
assessment be done later by a nurse. As the student nurse charts the interaction, which statement
is the best way to document what happened?
a. Appears to be in pain as evidenced by grouchy behavior
b. Behavior is inappropriate, requests registered nurse do the assessment
c. States, I want a registered nurse to do my assessment
d. Is grumpy, registered nurse notified
ANS: C
When a nurse collects objective data, he or she should apply critical thinking intellectual
standards (e.g., clear, precise, and consistent). Nurses do not include personal interpretive
statements. The timely, thorough, and accurate communication of facts is necessary to ensure
continuity and appropriateness of patient care. If you do not report or record an assessment
finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient.
Grouchy, inappropriate, and grumpy are personal interpretive statements and should be avoided.
PTS:1DIF:Cognitive Level: Analyzing (Analysis)
