PDF | Nursing | Galen College
1. Which of the following best describes the primary purpose of the clinical
judgment model in nursing practice?
A) To replace the nursing process with a simpler framework
B) To provide a structured approach for making patient care decisions
C) To determine the patient's medical diagnosis
D) To document patient care activities for reimbursement
Correct Answer: To provide a structured approach for making patient care
decisions
Rationale: The clinical judgment model provides a structured framework for
observing, interpreting, responding to, and reflecting on patient data to make
informed care decisions. It complements the nursing process rather than
replacing it. It does not determine medical diagnoses or serve primarily as a
documentation tool. This model enhances clinical reasoning and decision-
making in nursing practice.
2. What is the primary function of the assessment phase in the nursing process?
A) To establish patient goals and expected outcomes
B) To systematically collect and analyze patient data
C) To implement nursing interventions based on evidence
D) To evaluate the effectiveness of nursing care
,Correct Answer: To systematically collect and analyze patient data
Rationale: The assessment phase is the first step of the nursing process,
involving the systematic collection of subjective and objective data through
history taking, physical examination, and diagnostic testing. This data forms the
foundation for identifying patient problems and planning care. Goal setting
occurs during planning, implementation involves carrying out interventions, and
evaluation determines whether outcomes were met.
3. A nurse is performing an admission assessment. Which of the following
findings is considered objective data?
A) The patient's respiratory rate is 22 breaths per minute
B) The patient states they feel nauseated after eating
C) The patient reports a pain level of 6 out of 10
D) The patient complains of feeling dizzy when standing
Correct Answer: The patient's respiratory rate is 22 breaths per minute
Rationale: Objective data are observable and measurable signs, such as vital
signs, lung sounds, and laboratory values. Subjective data are what the patient
says or feels, including pain, nausea, and dizziness. The respiratory rate is a
measurable vital sign, making it objective data.
4. When planning care for a patient, which nursing diagnosis takes the highest
priority according to Maslow's Hierarchy of Needs?
, A) Risk for loneliness related to social isolation
B) Deficient knowledge related to new medication regimen
C) Ineffective airway clearance related to retained secretions
D) Low self-esteem related to body image changes
Correct Answer: Ineffective airway clearance related to retained secretions
Rationale: Physiological needs, particularly those related to airway, breathing,
and circulation (ABCs), are the highest priority in Maslow's hierarchy. Ineffective
airway clearance directly threatens oxygenation and ventilation, making it the
most urgent problem. Psychosocial and educational needs are addressed after
physiological stability is ensured.
5. What is the primary purpose of the 'Implementation' phase of the nursing
process?
A) Collecting data about the patient's health status
B) Setting measurable goals with the patient
C) Performing the nursing actions identified in the care plan
D) Determining if the patient's goals were met
Correct Answer: Performing the nursing actions identified in the care plan
Rationale: Implementation involves carrying out the planned nursing
interventions. This phase includes direct patient care, medication