A nurse assesses that a patient has slurred speech and a retained bolus of food in the mouth. The presence of
which additional patient assessments should be clustered with this group of signs and symptoms? Select all
that apply
A. Dyspepsia
B. Coughing
C. Drooling
D. Gurgling
E. Plaque - ansB. Coughing
A nurse collects information about a patient. Which should the nurse do next?
A. Plan nursing interventions
B. Write patient-centered goals
C. Formulate nursing diagnosis
D. Determine significance of the data - ansD. Determine significance of the data
A nurse concludes that a patient's elevated temperature, pulse and respirations are significant. Which step of
the nursing process is being used when the nurse comes to this conclusion?
A. Implementation
B. Assessment
C. Evaluation
D. Analysis - ansD. Analysis
A nurse evaluates a patient's response to a nursing intervention. To which aspect of the nursing process is this
evaluation most directly related?
A. Goal
B. Problem
, C. Etiology
D. Implementation - ansA. Goal
A nurse is caring for a patient with a fever. Which is a well-designed goal for this patient?
A. The patient will have a lower temperature.
B. The patient will be taught how to take an accurate temperature.
C. The patient will maintain fluid intake adequate to prevent dehydration.
D. The patient will be given aspirin every eight hours whenever necessary. - ansC. The patient will maintain
fluid intake adequate to prevent dehydration.
A nurse is caring for a patient with urinary elimination problem. Which are accurately stated goals? Select all
that apply
A. 'The patient will be taught how to use a bedpan while on bed-rest.'
B. 'The patient will experience fewer incontinence episodes at night.'
C. 'The patient will transfer independently and safely to a toilet before discharge.'
D. 'The patient will be assisted to the commode every two hours and whenever necessary.'
E. 'The patient will experience one or less events of urinary incontinence daily within 6 weeks.' - ansC. 'The
patient will transfer independently and safely to a toilet before discharge.'
E. 'The patient will experience one or less events of urinary incontinence daily within 6 weeks.'
A nurse is collecting subjective data associated with a patient's anxiety. Which assessment method should be
used to collect this information?
A. Observing
B. Inspecting
C. Auscultation
D. Interviewing - ansD. Interviewing
A nurse is interviewing a patient. Which patient statements are examples of objective data? Select all that
apply