Solutions
The use of critical thinking skills during the assessment phase of
the nursing process ensures
that the nurse
a. Completes a comprehensive database.
b. Identifies pertinent nursing diagnoses.
c. Intervenes based on patient goals and priorities of care.
d. Determines whether outcomes have been achieved. Correct
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Answers ANS: A
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The assessment phase of the nursing process involves data
collection to complete a thorough patient database. Identifying
nursing diagnoses occurs during the diagnosis phase. The nurse
carries out interventions during the implementation phase, and
determining whether outcomes
have been achieved takes place during the evaluation phase of
the nursing process
A nurse using the problem-oriented approach to data collection
will first
a. Complete an observational overview.
b. Disregard cues and complete the database questions in
chronological order.
c. Focus on the patient's presenting situation.
d. Make accurate interpretations of the data. Correct Answers
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ANS: C
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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
After reviewing the database, the nurse discovers that the
patient's vital signs have not been recorded by the nursing
assistant. With this in mind, what clinical decision should the
nurse make?
a. Administer scheduled medications assuming she would have
been informed if the vital signs were abnormal.
b. Have the patient transported to the radiology department for a
scheduled x-ray, and review vital signs upon return.
c. Ask the nursing assistant to record the patient's vital signs
before administering medications.
d. Omit the vital signs because the patient is presently in no
distress. Correct Answers ANS: C
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The nurse should ask the nursing assistant to record the vital
signs for review before administering medicines or transporting
the patient to another department. The nurse should not make
assumptions when providing high-quality patient care, and
omitting the vital signs is not an appropriate action
Subjective data include
a. A patient's feelings, perceptions, and reported symptoms.
b. A description of the patient's behavior.
c. Observations of a patient's health status.
d. Measurements of a patient's health status Correct Answers
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ANS: A
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