,NUR 256 Exam 1 | Concepts of Mental Health Nursing (2026/2027) PDF |
Galen College
1. Which of the following best describes the primary purpose of the
nursing process?
A) To diagnose and treat medical diseases independently
B) To provide a systematic framework for delivering individualized
patient care
C) To prescribe medications and treatments without provider orders
D) To replace the need for clinical judgment in nursing practice
Correct Answer: To provide a systematic framework for delivering
individualized patient care
Rationale: The nursing process is a systematic, five-step framework
(assessment, diagnosis, planning, implementation, evaluation) that
guides nurses in delivering holistic, patient-centered care. It promotes
clinical reasoning and individualized interventions rather than rigid
standardization. It does not diagnose medical diseases, prescribe
treatments independently, or replace clinical judgment.
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. According to the NCSBN Clinical Judgment Measurement Model,
which layer immediately follows "Analyze Cues"?
A) Take Actions
B) Recognize Cues
C) Prioritize Hypotheses
D) Evaluate Outcomes
Correct Answer: Prioritize Hypotheses
Rationale: The NCSBN CJMM consists of six layers: Recognize Cues,
Analyze
, Cues, Prioritize Hypotheses, Generate Solutions, Take Actions, and
Evaluate Outcomes. After analyzing cues, the nurse prioritizes
hypotheses to determine which patient problems are most urgent.
Taking actions and evaluating outcomes occur later in the model.
4. A nurse is caring for a client who is 24 hours postoperative from
abdominal surgery. Which finding requires immediate intervention?
A) A temperature of 37.8 degrees Celsius
B) A heart rate of 96 beats per minute
C) A urinary output of 20 mL per hour
D) A blood pressure of 118/76 mmHg
Correct Answer: A urinary output of 20 mL per hour
Rationale: Urinary output below 30 mL per hour indicates inadequate
renal perfusion and may signal hypovolemia, shock, or urinary tract
obstruction. Immediate intervention is required to prevent acute
kidney injury. A low-grade temperature and mild tachycardia are
common postoperative findings. A blood pressure of 118/76 mmHg is
within normal limits.
5. Which term refers to the movement of a body part toward the
midline of the body?
A) Abduction
Galen College
1. Which of the following best describes the primary purpose of the
nursing process?
A) To diagnose and treat medical diseases independently
B) To provide a systematic framework for delivering individualized
patient care
C) To prescribe medications and treatments without provider orders
D) To replace the need for clinical judgment in nursing practice
Correct Answer: To provide a systematic framework for delivering
individualized patient care
Rationale: The nursing process is a systematic, five-step framework
(assessment, diagnosis, planning, implementation, evaluation) that
guides nurses in delivering holistic, patient-centered care. It promotes
clinical reasoning and individualized interventions rather than rigid
standardization. It does not diagnose medical diseases, prescribe
treatments independently, or replace clinical judgment.
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. According to the NCSBN Clinical Judgment Measurement Model,
which layer immediately follows "Analyze Cues"?
A) Take Actions
B) Recognize Cues
C) Prioritize Hypotheses
D) Evaluate Outcomes
Correct Answer: Prioritize Hypotheses
Rationale: The NCSBN CJMM consists of six layers: Recognize Cues,
Analyze
, Cues, Prioritize Hypotheses, Generate Solutions, Take Actions, and
Evaluate Outcomes. After analyzing cues, the nurse prioritizes
hypotheses to determine which patient problems are most urgent.
Taking actions and evaluating outcomes occur later in the model.
4. A nurse is caring for a client who is 24 hours postoperative from
abdominal surgery. Which finding requires immediate intervention?
A) A temperature of 37.8 degrees Celsius
B) A heart rate of 96 beats per minute
C) A urinary output of 20 mL per hour
D) A blood pressure of 118/76 mmHg
Correct Answer: A urinary output of 20 mL per hour
Rationale: Urinary output below 30 mL per hour indicates inadequate
renal perfusion and may signal hypovolemia, shock, or urinary tract
obstruction. Immediate intervention is required to prevent acute
kidney injury. A low-grade temperature and mild tachycardia are
common postoperative findings. A blood pressure of 118/76 mmHg is
within normal limits.
5. Which term refers to the movement of a body part toward the
midline of the body?
A) Abduction
