,Chapter 01: Professional Nursing Practice
ss ss ss ss
Lewis: Medical-Surgical Nursing, 10th Edition
ss ss ss ss ss
MULTIPLE ssCHOICE
1. The ssnurse sscompletes ssan ssadmission ssdatabase ssand ssexplains ssthat ssthe ssplan ssof sscare ssand
ssdischarge ssgoals sswill ssbe ssdeveloped sswith ssthe sspatient‘s ssinput. ssThe sspatient ssstates, ss―How ssis
ssthis ssdifferent ssfrom sswhat ssthe ssdoctor ssdoes?‖ ssWhich ssresponse sswould ssbe ssmost ssappropriate
ssfor ssthe ssnurse ssto ssmake?
a. ―The ssrole ssof ssthe ssnurse ssis ssto ssadminister ssmedications ssand ssother sstreatments
ssprescribed ssby ss your ssdoctor.‖
b. ―The ssnurse‘s ssjob ssis ssto sshelp ssthe ssdoctor ssby sscollecting ssinformation
ssand sscommunicating ssany ssproblems ssthat ssoccur.‖
c. ―Nurses ssperform ssmany ssof ssthe sssame ssprocedures ssas ssthe ssdoctor, ssbut ssnurses ssare
sswith ssthe sspatients ssfor ssa sslonger sstime ssthadoctor.‖
d. ―In ssaddition ssto sscaring ssfor ssyou sswhile ssyou ssare sssick, ssthe ssnurses sswill ssassist
ssyou ssto ssdevelop ssan ssindividualized ssplan ssto ssmaintain ssyour sshealth.‖
ANS: s s D
This ssresponse ssis ssconsistent sswith ssthe ssAmerican ssNurses ssAssociation ss(ANA) ssdefinition ssof
ssnursing, sswhich ssdescribes ssthe ssrole ssof ssnurses ssin sspromoting sshealth. ssThe ssother ssresponses
ssdescribe sssome ssof ssthe ssdependent ssand sscollaborative ssfunctions ssof ssthe ssnursing ssrole ssbut ssdo ssnot
ssaccurately ssdescribe ssthe ssnurse‘s ssrole ssin ssthe sshealth sscare sssystem.
DIF: Cognitive ssLevel: ssUnderstand ss(comprehension) REF: s s s s 3
TOP: s s Nursing ssProcess: ssImplementation MSC: s s NCLEX: ssSafe ssand ssEffective ssCare ssEnvironment
2. The ssnurse ssdescribes ssto ssa ssstudent ssnurse sshow ssto ssuse ssevidence-based sspractice ssguidelines
sswhen sscaring ssfor sspatients. ssWhich ssstatement, ssif ssmade ssby ssthe ssnurse, sswould ssbe ssthe ssmost
ssaccurate?
a. ―Inferences ssfrom ssclinical ssresearch ssstudies ssare ssused ssas ssa ssguide.‖
b. ―Patient sscare ssis ssbased sson ssclinical ssjudgment, ssexperience, ssand sstraditions.‖
c. ―Data ssare ssevaluated ssto ssshow ssthat ssthe sspatient ssoutcomes ssare ssconsistently ssmet.‖
d. ―Recommendations ssare ssbased sson ssresearch, ssclinical ssexpertise, ssand
sspatient sspreferences.‖
ANS: s s D
Evidence-based sspractice ss(EBP) ssis ssthe ssuse ssof ssthe ssbest ssresearch-based ssevidence sscombined
sswith ssclinician ssexpertise. ssClinical ssjudgment ssbased sson ssthe ssnurse‘s ssclinical ssexperience ssis sspart ssof
ssEBP, ssbut ssclinical ssdecision ssmaking ssshould ssalso ssincorporate sscurrent ssresearch ssand ssresearch-
based ssguidelines. ssEvaluation ssof sspatient ssoutcomes ssis ssimportant, ssbut ssinterventions ssshould ssbe
ssbased sson ssresearch ssfrom ssrandomized sscontrol ssstudies sswith ssa sslarge ssnumber ssof sssubjects.
DIF: Cognitive ssLevel: ssRemember ss(knowledge) REF: s s s s 15
TOP: s s Nursing ssProcess: ssPlanning MSC: s s NCLEX: ssSafe ssand ssEffective ssCare ssEnvironment
3. The ssnurse ssteaches ssa ssstudent ssnurse ssabout sshow ssto ssapply ssthe ssnursing ssprocess sswhen ssproviding
patient sscare. ssWhich ssstatement, ssif ssmade ssby ssthe ssstudent ssnurse, ssindicates ssthat ssteaching sswas
ss
successful?
ss
a. ―The ssnursing ssprocess ssis ssa ssscientific-based ssmethod ssof ssdiagnosing ssthe sspatient‘s
, health sscare ssproblems.‖
b. ―The ssnursing ssprocess ssis ssa ssproblem-solving sstool ssused ssto ssidentify ssand sstreat
patients‘ sshealth sscare ssneeds.‖
ss
c. ―The ssnursing ssprocess ssis ssused ssprimarily ssto ssexplain ssnursing ssinterventions ssto
other sshealth sscare ssprofessionals.‖
ss
d. ―The ssnursing ssprocess ssis ssbased sson ssnursing sstheory ssthat ssincorporates
the ssbiopsychosocial ssnature ssof sshumans.‖
ss
ANS: s s B
The ssnursing ssprocess ssis ssa ssproblem-solving ssapproach ssto ssthe ssidentification ssand sstreatment ssof
sspatients‘ ssproblems. ssDiagnosis ssis ssonly ssone ssphase ssof ssthe ssnursing ssprocess. ssThe ssprimary ssuse
ssof ssthe ssnursing ssprocess ssis ssin sspatient sscare, ssnot ssto ssestablish ssnursing sstheory ssor ssexplain ssnursing
ssinterventions ssto ssother sshealth sscare ssprofessionals.
DIF: Cognitive ssLevel: ssUnderstand ss(comprehension) REF: s s s s 5
TOP: s s Nursing ssProcess: ssImplementation MSC: s s NCLEX: ssSafe ssand ssEffective ssCare ssEnvironment
4. A sspatient sshas ssbeen ssadmitted ssto ssthe sshospital ssfor sssurgery ssand sstells ssthe ssnurse, ss―I ssdo ssnot
ssfeel sscomfortable ssleaving ssmy sschildren sswith ssmy ssparents.‖ ssWhich ssaction ssshould ssthe ssnurse
sstake ssnext?
a. Reassure ssthe sspatient ssthat ssthese ssfeelings ssare sscommon ssfor ssparents.
b. Have ssthe sspatient sscall ssthe sschildren ssto ssensure ssthat ssthey ssare ssdoing sswell.
c. Gather ssmore ssdata ssabout ssthe sspatient‘s ssfeelings ssabout ssthe sschild-care ssarrangements.
d. Call ssthe sspatient‘s ssparents ssto ssdetermine sswhether ssadequate sschild sscare ssis
ssbeing ssprovided.
ANS: s s C
Because ssa sscomplete ssassessment ssis ssnecessary ssin ssorder ssto ssidentify ssa ssproblem ssand sschoose ssan
ssappropriate ssintervention, ssthe ssnurse‘s ssfirst ssaction ssshould ssbe ssto ssobtain ssmore ssinformation. ssThe
ssother ssactions ssmay ssbe ssappropriate, ssbut ssmore ssassessment ssis ssneeded ssbefore ssthe ssbest
ssintervention sscan ssbe sschosen.
DIF: Cognitive ssLevel: ssApply ss(application) REF: 6
OBJ: s s Special ssQuestions: ssPrioritization TOP: s s Nursing ssProcess:
ssAssessment ssMSC: s s NCLEX: ssPsychosocial ssIntegrity
5. A sspatient sswho ssis ssparalyzed sson ssthe ssleft ssside ssof ssthe ssbody ssafter ssa ssstroke ssdevelops ssa sspressure
ulcer sson ssthe ssleft sship. ssWhich ssnursing ssdiagnosis ssis ssmost ssappropriate?
ss
a. Impaired ssphysical ssmobility ssrelated ssto ssleft-sided ssparalysis
b. Risk ssfor ssimpaired sstissue ssintegrity ssrelated ssto ssleft-sided ssweakness
c. Impaired ssskin ssintegrity ssrelated ssto ssaltered sscirculation ssand sspressure
d. Ineffective sstissue ssperfusion ssrelated ssto ssinability ssto ssmove ssindependently
ANS: s s C
The sspatient‘s ssmajor ssproblem ssis ssthe ssimpaired ssskin ssintegrity ssas ssdemonstrated ssby ssthe sspresence
ssof ssa sspressure ssulcer. ssThe ssnurse ssis ssable ssto sstreat ssthe sscause ssof ssaltered sscirculation ssand
sspressure ssby ssfrequently ssrepositioning ssthe sspatient. ssAlthough ssleft-sided ssweakness ssis ssa
ssproblem ssfor ssthe sspatient, ssthe ssnurse sscannot sstreat ssthe ssweakness. ssThe ss―risk ssfor‖ ssdiagnosis ssis
ssnot ssappropriate ssfor ssthis sspatient, sswho ssalready sshas ssimpaired sstissue ssintegrity. ssThe sspatient ssdoes
sshave ssineffective sstissue ssperfusion, ssbut ssthe ssimpaired ssskin ssintegrity ssdiagnosis ssindicates ssmore
ssclearly sswhat ssthe sshealth ssproblem ssis.
, DIF: Cognitive ssLevel: ssApply ss(application) REF: 7
TOP: s s Nursing ssProcess: ssDiagnosis MSC: s s NCLEX: ssPhysiological ssIntegrity
6. A sspatient sswith ssa ssbacterial ssinfection sshas ssa ssnursing ssdiagnosis ssof ssdeficient ssfluid ssvolume
ssrelated ssto ssexcessive ssdiaphoresis. ssWhich ssoutcome sswould ssthe ssnurse ssrecognize ssas ssappropriate
ssfor ssthis sspatient?
a. Patient sshas ssa ssbalanced ssintake ssand ssoutput.
b. Patient‘s ssbedding ssis sschanged sswhen ssit ssbecomes ssdamp.
c. Patient ssunderstands ssthe ssneed ssfor ssincreased ssfluid ssintake.
d. Patient‘s ssskin ssremains sscool ssand ssdry ssthroughout sshospitalization.
ANS: s s A
This ssstatement ssgives ssmeasurable ssdata ssshowing ssresolution ssof ssthe ssproblem ssof ssdeficient ssfluid
ssvolume ssthat sswas ssidentified ssin ssthe ssnursing ssdiagnosis ssstatement. ssThe ssother ssstatements sswould
ssnot ssindicate ssthat ssthe ssproblem ssof ssdeficient ssfluid ssvolume sswas ssresolved.
DIF: Cognitive ssLevel: ssApply ss(application) REF: 7
TOP: s s Nursing ssProcess: ssPlanning MSC: s s NCLEX: ssPhysiological ssIntegrity
7. A ssnurse ssasks ssthe sspatient ssif sspain sswas ssrelieved ssafter ssreceiving ssmedication. ssWhat ssis ssthe
purpose ssof ssthe ssevaluation ssphase ssof ssthe ssnursing ssprocess?
ss
a. To ssdetermine ssif ssinterventions sshave ssbeen sseffective ssin ssmeeting sspatient ssoutcomes
b. To ssdocument ssthe ssnursing sscare ssplan ssin ssthe ssprogress ssnotes ssof ssthe ssmedical ssrecord
c. To ssdecide sswhether ssthe sspatient‘s sshealth ssproblems sshave ssbeen sscompletely ssresolved
d. To ssestablish ssif ssthe sspatient ssagrees ssthat ssthe ssnursing sscare ssprovided sswas sssatisfactory
ANS: s s A
Evaluation ssconsists ssof ssdetermining sswhether ssthe ssdesired sspatient ssoutcomes sshave ssbeen ssmet
ssand sswhether ssthe ssnursing ssinterventions sswere ssappropriate. ssThe ssother ssresponses ssdo ssnot
ssdescribe ssthe ssevaluation ssphase.
DIF: Cognitive ssLevel: ssUnderstand ss(comprehension) REF: 5
TOP: s s Nursing ssProcess: ssEvaluation MSC: s s NCLEX: ssSafe ssand ssEffective ssCare ssEnvironment
8. The ssnurse ssinterviews ssa sspatient sswhile sscompleting ssthe sshealth sshistory ssand ssphysical
examination. ssWhat ssis ssthe sspurpose ssof ssthe ssassessment ssphase ssof ssthe ssnursing ssprocess?
ss
a. To ssteach ssinterventions ssthat ssrelieve sshealth ssproblems
b. To ssuse sspatient ssdata ssto ssevaluate sspatient sscare ssoutcomes
c. To ssobtain ssdata sswith sswhich ssto ssdiagnose sspatient ssproblems
d. To sshelp ssthe sspatient ssidentify ssrealistic ssoutcomes ssfor sshealth ssproblems
ANS: s s C
During ssthe ssassessment ssphase, ssthe ssnurse ssgathers ssinformation ssabout ssthe sspatient ssto ssdiagnose
sspatient ssproblems. ssThe ssother ssresponses ssare ssexamples ssof ssthe ssplanning, ssintervention, ssand
ssevaluation ssphases ssof ssthe ssnursing ssprocess.
DIF: Cognitive ssLevel: ssUnderstand ss(comprehension) REF: 5
TOP: s s Nursing ssProcess: ssAssessment MSC: s s NCLEX: ssSafe ssand ssEffective ssCare ssEnvironment
ss ss ss ss
Lewis: Medical-Surgical Nursing, 10th Edition
ss ss ss ss ss
MULTIPLE ssCHOICE
1. The ssnurse sscompletes ssan ssadmission ssdatabase ssand ssexplains ssthat ssthe ssplan ssof sscare ssand
ssdischarge ssgoals sswill ssbe ssdeveloped sswith ssthe sspatient‘s ssinput. ssThe sspatient ssstates, ss―How ssis
ssthis ssdifferent ssfrom sswhat ssthe ssdoctor ssdoes?‖ ssWhich ssresponse sswould ssbe ssmost ssappropriate
ssfor ssthe ssnurse ssto ssmake?
a. ―The ssrole ssof ssthe ssnurse ssis ssto ssadminister ssmedications ssand ssother sstreatments
ssprescribed ssby ss your ssdoctor.‖
b. ―The ssnurse‘s ssjob ssis ssto sshelp ssthe ssdoctor ssby sscollecting ssinformation
ssand sscommunicating ssany ssproblems ssthat ssoccur.‖
c. ―Nurses ssperform ssmany ssof ssthe sssame ssprocedures ssas ssthe ssdoctor, ssbut ssnurses ssare
sswith ssthe sspatients ssfor ssa sslonger sstime ssthadoctor.‖
d. ―In ssaddition ssto sscaring ssfor ssyou sswhile ssyou ssare sssick, ssthe ssnurses sswill ssassist
ssyou ssto ssdevelop ssan ssindividualized ssplan ssto ssmaintain ssyour sshealth.‖
ANS: s s D
This ssresponse ssis ssconsistent sswith ssthe ssAmerican ssNurses ssAssociation ss(ANA) ssdefinition ssof
ssnursing, sswhich ssdescribes ssthe ssrole ssof ssnurses ssin sspromoting sshealth. ssThe ssother ssresponses
ssdescribe sssome ssof ssthe ssdependent ssand sscollaborative ssfunctions ssof ssthe ssnursing ssrole ssbut ssdo ssnot
ssaccurately ssdescribe ssthe ssnurse‘s ssrole ssin ssthe sshealth sscare sssystem.
DIF: Cognitive ssLevel: ssUnderstand ss(comprehension) REF: s s s s 3
TOP: s s Nursing ssProcess: ssImplementation MSC: s s NCLEX: ssSafe ssand ssEffective ssCare ssEnvironment
2. The ssnurse ssdescribes ssto ssa ssstudent ssnurse sshow ssto ssuse ssevidence-based sspractice ssguidelines
sswhen sscaring ssfor sspatients. ssWhich ssstatement, ssif ssmade ssby ssthe ssnurse, sswould ssbe ssthe ssmost
ssaccurate?
a. ―Inferences ssfrom ssclinical ssresearch ssstudies ssare ssused ssas ssa ssguide.‖
b. ―Patient sscare ssis ssbased sson ssclinical ssjudgment, ssexperience, ssand sstraditions.‖
c. ―Data ssare ssevaluated ssto ssshow ssthat ssthe sspatient ssoutcomes ssare ssconsistently ssmet.‖
d. ―Recommendations ssare ssbased sson ssresearch, ssclinical ssexpertise, ssand
sspatient sspreferences.‖
ANS: s s D
Evidence-based sspractice ss(EBP) ssis ssthe ssuse ssof ssthe ssbest ssresearch-based ssevidence sscombined
sswith ssclinician ssexpertise. ssClinical ssjudgment ssbased sson ssthe ssnurse‘s ssclinical ssexperience ssis sspart ssof
ssEBP, ssbut ssclinical ssdecision ssmaking ssshould ssalso ssincorporate sscurrent ssresearch ssand ssresearch-
based ssguidelines. ssEvaluation ssof sspatient ssoutcomes ssis ssimportant, ssbut ssinterventions ssshould ssbe
ssbased sson ssresearch ssfrom ssrandomized sscontrol ssstudies sswith ssa sslarge ssnumber ssof sssubjects.
DIF: Cognitive ssLevel: ssRemember ss(knowledge) REF: s s s s 15
TOP: s s Nursing ssProcess: ssPlanning MSC: s s NCLEX: ssSafe ssand ssEffective ssCare ssEnvironment
3. The ssnurse ssteaches ssa ssstudent ssnurse ssabout sshow ssto ssapply ssthe ssnursing ssprocess sswhen ssproviding
patient sscare. ssWhich ssstatement, ssif ssmade ssby ssthe ssstudent ssnurse, ssindicates ssthat ssteaching sswas
ss
successful?
ss
a. ―The ssnursing ssprocess ssis ssa ssscientific-based ssmethod ssof ssdiagnosing ssthe sspatient‘s
, health sscare ssproblems.‖
b. ―The ssnursing ssprocess ssis ssa ssproblem-solving sstool ssused ssto ssidentify ssand sstreat
patients‘ sshealth sscare ssneeds.‖
ss
c. ―The ssnursing ssprocess ssis ssused ssprimarily ssto ssexplain ssnursing ssinterventions ssto
other sshealth sscare ssprofessionals.‖
ss
d. ―The ssnursing ssprocess ssis ssbased sson ssnursing sstheory ssthat ssincorporates
the ssbiopsychosocial ssnature ssof sshumans.‖
ss
ANS: s s B
The ssnursing ssprocess ssis ssa ssproblem-solving ssapproach ssto ssthe ssidentification ssand sstreatment ssof
sspatients‘ ssproblems. ssDiagnosis ssis ssonly ssone ssphase ssof ssthe ssnursing ssprocess. ssThe ssprimary ssuse
ssof ssthe ssnursing ssprocess ssis ssin sspatient sscare, ssnot ssto ssestablish ssnursing sstheory ssor ssexplain ssnursing
ssinterventions ssto ssother sshealth sscare ssprofessionals.
DIF: Cognitive ssLevel: ssUnderstand ss(comprehension) REF: s s s s 5
TOP: s s Nursing ssProcess: ssImplementation MSC: s s NCLEX: ssSafe ssand ssEffective ssCare ssEnvironment
4. A sspatient sshas ssbeen ssadmitted ssto ssthe sshospital ssfor sssurgery ssand sstells ssthe ssnurse, ss―I ssdo ssnot
ssfeel sscomfortable ssleaving ssmy sschildren sswith ssmy ssparents.‖ ssWhich ssaction ssshould ssthe ssnurse
sstake ssnext?
a. Reassure ssthe sspatient ssthat ssthese ssfeelings ssare sscommon ssfor ssparents.
b. Have ssthe sspatient sscall ssthe sschildren ssto ssensure ssthat ssthey ssare ssdoing sswell.
c. Gather ssmore ssdata ssabout ssthe sspatient‘s ssfeelings ssabout ssthe sschild-care ssarrangements.
d. Call ssthe sspatient‘s ssparents ssto ssdetermine sswhether ssadequate sschild sscare ssis
ssbeing ssprovided.
ANS: s s C
Because ssa sscomplete ssassessment ssis ssnecessary ssin ssorder ssto ssidentify ssa ssproblem ssand sschoose ssan
ssappropriate ssintervention, ssthe ssnurse‘s ssfirst ssaction ssshould ssbe ssto ssobtain ssmore ssinformation. ssThe
ssother ssactions ssmay ssbe ssappropriate, ssbut ssmore ssassessment ssis ssneeded ssbefore ssthe ssbest
ssintervention sscan ssbe sschosen.
DIF: Cognitive ssLevel: ssApply ss(application) REF: 6
OBJ: s s Special ssQuestions: ssPrioritization TOP: s s Nursing ssProcess:
ssAssessment ssMSC: s s NCLEX: ssPsychosocial ssIntegrity
5. A sspatient sswho ssis ssparalyzed sson ssthe ssleft ssside ssof ssthe ssbody ssafter ssa ssstroke ssdevelops ssa sspressure
ulcer sson ssthe ssleft sship. ssWhich ssnursing ssdiagnosis ssis ssmost ssappropriate?
ss
a. Impaired ssphysical ssmobility ssrelated ssto ssleft-sided ssparalysis
b. Risk ssfor ssimpaired sstissue ssintegrity ssrelated ssto ssleft-sided ssweakness
c. Impaired ssskin ssintegrity ssrelated ssto ssaltered sscirculation ssand sspressure
d. Ineffective sstissue ssperfusion ssrelated ssto ssinability ssto ssmove ssindependently
ANS: s s C
The sspatient‘s ssmajor ssproblem ssis ssthe ssimpaired ssskin ssintegrity ssas ssdemonstrated ssby ssthe sspresence
ssof ssa sspressure ssulcer. ssThe ssnurse ssis ssable ssto sstreat ssthe sscause ssof ssaltered sscirculation ssand
sspressure ssby ssfrequently ssrepositioning ssthe sspatient. ssAlthough ssleft-sided ssweakness ssis ssa
ssproblem ssfor ssthe sspatient, ssthe ssnurse sscannot sstreat ssthe ssweakness. ssThe ss―risk ssfor‖ ssdiagnosis ssis
ssnot ssappropriate ssfor ssthis sspatient, sswho ssalready sshas ssimpaired sstissue ssintegrity. ssThe sspatient ssdoes
sshave ssineffective sstissue ssperfusion, ssbut ssthe ssimpaired ssskin ssintegrity ssdiagnosis ssindicates ssmore
ssclearly sswhat ssthe sshealth ssproblem ssis.
, DIF: Cognitive ssLevel: ssApply ss(application) REF: 7
TOP: s s Nursing ssProcess: ssDiagnosis MSC: s s NCLEX: ssPhysiological ssIntegrity
6. A sspatient sswith ssa ssbacterial ssinfection sshas ssa ssnursing ssdiagnosis ssof ssdeficient ssfluid ssvolume
ssrelated ssto ssexcessive ssdiaphoresis. ssWhich ssoutcome sswould ssthe ssnurse ssrecognize ssas ssappropriate
ssfor ssthis sspatient?
a. Patient sshas ssa ssbalanced ssintake ssand ssoutput.
b. Patient‘s ssbedding ssis sschanged sswhen ssit ssbecomes ssdamp.
c. Patient ssunderstands ssthe ssneed ssfor ssincreased ssfluid ssintake.
d. Patient‘s ssskin ssremains sscool ssand ssdry ssthroughout sshospitalization.
ANS: s s A
This ssstatement ssgives ssmeasurable ssdata ssshowing ssresolution ssof ssthe ssproblem ssof ssdeficient ssfluid
ssvolume ssthat sswas ssidentified ssin ssthe ssnursing ssdiagnosis ssstatement. ssThe ssother ssstatements sswould
ssnot ssindicate ssthat ssthe ssproblem ssof ssdeficient ssfluid ssvolume sswas ssresolved.
DIF: Cognitive ssLevel: ssApply ss(application) REF: 7
TOP: s s Nursing ssProcess: ssPlanning MSC: s s NCLEX: ssPhysiological ssIntegrity
7. A ssnurse ssasks ssthe sspatient ssif sspain sswas ssrelieved ssafter ssreceiving ssmedication. ssWhat ssis ssthe
purpose ssof ssthe ssevaluation ssphase ssof ssthe ssnursing ssprocess?
ss
a. To ssdetermine ssif ssinterventions sshave ssbeen sseffective ssin ssmeeting sspatient ssoutcomes
b. To ssdocument ssthe ssnursing sscare ssplan ssin ssthe ssprogress ssnotes ssof ssthe ssmedical ssrecord
c. To ssdecide sswhether ssthe sspatient‘s sshealth ssproblems sshave ssbeen sscompletely ssresolved
d. To ssestablish ssif ssthe sspatient ssagrees ssthat ssthe ssnursing sscare ssprovided sswas sssatisfactory
ANS: s s A
Evaluation ssconsists ssof ssdetermining sswhether ssthe ssdesired sspatient ssoutcomes sshave ssbeen ssmet
ssand sswhether ssthe ssnursing ssinterventions sswere ssappropriate. ssThe ssother ssresponses ssdo ssnot
ssdescribe ssthe ssevaluation ssphase.
DIF: Cognitive ssLevel: ssUnderstand ss(comprehension) REF: 5
TOP: s s Nursing ssProcess: ssEvaluation MSC: s s NCLEX: ssSafe ssand ssEffective ssCare ssEnvironment
8. The ssnurse ssinterviews ssa sspatient sswhile sscompleting ssthe sshealth sshistory ssand ssphysical
examination. ssWhat ssis ssthe sspurpose ssof ssthe ssassessment ssphase ssof ssthe ssnursing ssprocess?
ss
a. To ssteach ssinterventions ssthat ssrelieve sshealth ssproblems
b. To ssuse sspatient ssdata ssto ssevaluate sspatient sscare ssoutcomes
c. To ssobtain ssdata sswith sswhich ssto ssdiagnose sspatient ssproblems
d. To sshelp ssthe sspatient ssidentify ssrealistic ssoutcomes ssfor sshealth ssproblems
ANS: s s C
During ssthe ssassessment ssphase, ssthe ssnurse ssgathers ssinformation ssabout ssthe sspatient ssto ssdiagnose
sspatient ssproblems. ssThe ssother ssresponses ssare ssexamples ssof ssthe ssplanning, ssintervention, ssand
ssevaluation ssphases ssof ssthe ssnursing ssprocess.
DIF: Cognitive ssLevel: ssUnderstand ss(comprehension) REF: 5
TOP: s s Nursing ssProcess: ssAssessment MSC: s s NCLEX: ssSafe ssand ssEffective ssCare ssEnvironment
