,
,
, wertyuiouytretyuioiuytryuijopiuytryuiojuytyuiojuytcjikbvbhjnighfdxcghbjiuytryuiouytuiuyiuyhhijj
c. “The nursing process is used primarily to explain nursing interventions to other
health care professionals.”
d. “The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.”
ANS: B
The nursing process is a problem-solving approach to the identification and treatment of
patients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the
nursing process is in patient care, not to establish nursing theory or explain nursing
interventions to other health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A patient has been admitted to the hospital for surgery and tells the nurse, “I do not feel
SU
comfortable leaving my children with my parents.” Which action should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patient’s feelings about the child-care arrangements.
CC
d. Call the patient’s parents to determine whether adequate child care is being
provided.
ANS: C
Because a complete assessment is necessary in order to identify a problem and choose an
ES
appropriate intervention, the nurse’s first action should be to obtain more information. The
other actions may be appropriate, but more assessment is needed before the best intervention
can be chosen.
SH
DIF: Cognitive Level: Apply (application) REF: 6
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer
AN
on the left hip. Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
DS
ANS: C
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of
a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by
frequently repositioning the patient. Although left-sided weakness is a problem for the patient,
the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this patient,
who already has impaired tissue integrity. The patient does have ineffective tissue perfusion,
but the impaired skin integrity diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this
patient?
a. Patient has a balanced intake and output.
4
,
, wertyuiouytretyuioiuytryuijopiuytryuiojuytyuiojuytcjikbvbhjnighfdxcghbjiuytryuiouytuiuyiuyhhijj
c. “The nursing process is used primarily to explain nursing interventions to other
health care professionals.”
d. “The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.”
ANS: B
The nursing process is a problem-solving approach to the identification and treatment of
patients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the
nursing process is in patient care, not to establish nursing theory or explain nursing
interventions to other health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A patient has been admitted to the hospital for surgery and tells the nurse, “I do not feel
SU
comfortable leaving my children with my parents.” Which action should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patient’s feelings about the child-care arrangements.
CC
d. Call the patient’s parents to determine whether adequate child care is being
provided.
ANS: C
Because a complete assessment is necessary in order to identify a problem and choose an
ES
appropriate intervention, the nurse’s first action should be to obtain more information. The
other actions may be appropriate, but more assessment is needed before the best intervention
can be chosen.
SH
DIF: Cognitive Level: Apply (application) REF: 6
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer
AN
on the left hip. Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
DS
ANS: C
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of
a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by
frequently repositioning the patient. Although left-sided weakness is a problem for the patient,
the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this patient,
who already has impaired tissue integrity. The patient does have ineffective tissue perfusion,
but the impaired skin integrity diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to
excessive diaphoresis. Which outcome would the nurse recognize as appropriate for this
patient?
a. Patient has a balanced intake and output.
4
