,
,
, c. To decide whether the patient’s health problems have been completely resolved
d. To establish if the patient agrees that the nursing care provided was satisfactory
ANS: B
Evaluation consists of determining whether the desired patient outcomes have been met and
whether the nursing interventions were appropriate. The other responses do not describe the
evaluation phase.
DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
7. The nurse interviews a patient while completing the health history and physical examination.
What is the purpose of the assessment phase of the nursing process?
a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To help the patient identify realistic outcomes for health problems
d. To obtain data with which to diagnose patient strengths and problems
ANS: D
During the assessment phase, the nurse gathers information about the patient to diagnose
patient strengths and problems. The other responses are examples of the planning,
intervention, and evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
8. The nurse admits a patient to the hospital and develops a plan of care. What components
should the nurse include in thTeEpS TBtApro
atien NKblWOR
em stL
ateDm.eO
ntR
?G
a. The problem and the suggested patient goals or outcomes
b. The problem, its causes, and the signs and symptoms of the problem
c. The problem with the possible etiology and the planned interventions
d. The problem, the pathophysiology of the problem, and the expected outcome
ANS: B
When writing patient problems or nursing diagnoses, this format should be used: problem,
etiology, and signs and symptoms. The subjective as well as objective data should be
included. Goals, outcomes, and interventions are not included in the problem statement.
DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
9. Which patient care task is appropriate for the nurse to delegate to experienced unlicensed
assistive personnel (UAP)?
a. Instruct the patient about the need to alternate activity and rest.
b. Monitor level of shortness of breath or fatigue after ambulation.
c. Obtain the patient’s blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
UAP education includes accurate vital sign measurement. Assessment and patient teaching
require registered nurse education and scope of practice and cannot be delegated.
,
, c. To decide whether the patient’s health problems have been completely resolved
d. To establish if the patient agrees that the nursing care provided was satisfactory
ANS: B
Evaluation consists of determining whether the desired patient outcomes have been met and
whether the nursing interventions were appropriate. The other responses do not describe the
evaluation phase.
DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
7. The nurse interviews a patient while completing the health history and physical examination.
What is the purpose of the assessment phase of the nursing process?
a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To help the patient identify realistic outcomes for health problems
d. To obtain data with which to diagnose patient strengths and problems
ANS: D
During the assessment phase, the nurse gathers information about the patient to diagnose
patient strengths and problems. The other responses are examples of the planning,
intervention, and evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension)
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
8. The nurse admits a patient to the hospital and develops a plan of care. What components
should the nurse include in thTeEpS TBtApro
atien NKblWOR
em stL
ateDm.eO
ntR
?G
a. The problem and the suggested patient goals or outcomes
b. The problem, its causes, and the signs and symptoms of the problem
c. The problem with the possible etiology and the planned interventions
d. The problem, the pathophysiology of the problem, and the expected outcome
ANS: B
When writing patient problems or nursing diagnoses, this format should be used: problem,
etiology, and signs and symptoms. The subjective as well as objective data should be
included. Goals, outcomes, and interventions are not included in the problem statement.
DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
9. Which patient care task is appropriate for the nurse to delegate to experienced unlicensed
assistive personnel (UAP)?
a. Instruct the patient about the need to alternate activity and rest.
b. Monitor level of shortness of breath or fatigue after ambulation.
c. Obtain the patient’s blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
UAP education includes accurate vital sign measurement. Assessment and patient teaching
require registered nurse education and scope of practice and cannot be delegated.
