ACC 290 Foundations of Nursing 7th Edition

ACC 290 Foundations of Nursing 7th Edition Chapter 3: Documentation Foundations of Nursing 7th Edition MULTIPLE CHOICE 1. What does documentation of type of care, time of care, and signature of the person prove? a. The person wh b. No litigation ca c. Interventions d. The patient’s r ANS: C Documenting type of care, time of care, and signature of the person results in recording the interventions that are implemented to meet the patient’s needs. Many charting entries include doctor’s visits, presence of family, or interventions by other departments. Patient response to some interventions is not always positive. DIF: Cognitive Level: Comprehension REF: Page OBJ: 1 TOP: Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 2. Why is documentation especially significant in managed care? a. The hospital n b. Institutions are c. Patients might d. Documents ma ANS: B Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs); a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount. DIF: Cognitive Level: Comprehension REF: Page OBJ: 1 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation? a. SOAP b. Block c. CBE d. Focus ANS: C Charting additional treatments done, changes in a patient’s condition, and new concerns during the shift is charting by exception (CBE). DIF: Cognitive Level: Comprehension REF: Page 145 OBJ: 1| 5| 7 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. What form explains the lapse when events are not consistent with facility or national standards of expected care? a. Subjective dat b. Focus chart c. Incident report d. Nursing assess ANS: C An incident report is completed when patient care was not consistent with facility or national standards. The form explains the event, time, extent of injury, and who was notified. DIF: Cognitive Level: Knowledge REF: Page OBJ: 1| 7 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a: a. nursing order. b. Kardex. c. nursing care pl d. critical pathwa ANS: D Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type. DIF: Cognitive Level: Knowledge REF: Pages OBJ: 8 TOP: Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 6. What makes home health care documentation unique? a. Some charting b. The physician’ c. Different healt d. The physician ANS: C Home health care documentation has unique problems because of the need for different health care workers to access the medical record. DIF: Cognitive Level: Comprehension REF: Page OBJ: 9 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 7. What regulates standards for long-term care documentation? a. OBRA b. Title XXII c. Nursing diagno d. The care plan ANS: A OBRA (Omnibus Budget Reconciliation Act) was a significant Medicare and Medicaid legislation for long-term health care documentation. DIF: Cognitive Level: Knowledge REF: Page 152 OBJ: 10 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 8. What is the nurse required to do to adhere to the concept of confidentiality for the patient’s medical record? a. Provide inform b. Provide inform c. Share informat d. Have a clinical ANS: D The nurse should not read the patient’s medical record unless there is a clinical reason for doing so. DIF: Cognitive Level: Comprehension REF: Page 152 OBJ: 4 TOP: Confidentiality KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 9. Documentation is necessary for the evaluation of patient care. Of which phase of the nursing process is this an integral part? a. Assessment b. Planning c. Implementatio d. Evaluation ANS: C Documentation is part of the implementation phase of the nursing process. DIF: Cognitive Level: Comprehension REF: Page OBJ: 1| 4 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 10. What does the nurse use as a basis for documentation in focus charting? a. Problem list b. Nursing orders c. Nursing diagno d. Evaluation ANS: C In focus charting, instead of using the problem list, modified nursing diagnoses are used as an index for nursing documentation. DIF: Cognitive Level: Knowledge REF: Page 144 OBJ: 7 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 11. What is the purpose of QA (quality assurance)? a. To screen emp b. To evaluate ca c. To conduct in-s d. To report devia ANS: B QA is an in-house department that evaluates care services and results against accepted standards. DIF: Cognitive Level: Comprehension REF: Page OBJ: 1 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 12. What is the process used to appraise the practice of an individual nurse known as? a. Quality assura b. Incident report c. OBRA d. Peer review ANS: D Peer review is an in-house department study that may appraise the nursing practice of individual nurses. DIF: Cognitive Level: Knowledge REF: Page 139 OBJ: 4 TOP: Peer review KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 13. What is the documentation format that uses the acronym SOAPE? a. Problem-orient b. Focused c. Traditional d. Crisis ANS: A The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems/nursing diagnoses. DIF: Cognitive Level: Comprehension REF: Pages OBJ: TOP: Problem-oriented medical record (POMR) Process Step: N/A MSC: NCLEX: N/A 7 KEY: Nursing 14. Who is the legal owner of the patient’s medical record? a. Patient b. Physician c. Institution d. State ANS: C Ownership of a medical record belongs to the institution in the case of a hospitalized patient, or the physician in the case of private office visits. DIF: Cognitive Level: Knowledge REF: Page OBJ: 4 TOP: Legal ownership KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 15. When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered? a. Charting in cod b. Logging off c. Charting in pri d. Signing on wit ANS: B Logging off closes the computer file that was opened with the nurse’s password. Any other data entry will require that person to sign on with their password. DIF: Cognitive Level: Comprehension REF: Page OBJ: 2 TOP: Computer documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 16. What is the system that classifies patients by age, diagnosis, and surgical procedure and produces 300 different categories used for predicting the use of hospital resources? a. Quality assura b. Resource asse c. Quality improv d. Diagnosis-relat ANS: D Cost reimbursement rates under government plans are based on diagnosis-related groups (DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay. DIF: Cognitive Level: Knowledge REF: Page OBJ: 5 TOP: Diagnostic-related groups KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 17. A nurse is using the data, action, response, education (DARE) system of charting, and is completing the data portion. What data are the nurse’s focus? a. Planning b. Assessment c. Implementatio d. Patient teachin ANS: B DARE is the acronym for four different aspects of charting using the focus format. Data (D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education/patient teaching (E). DIF: Cognitive Level: Comprehension REF: Page OBJ: 7 TOP: Charting KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 18. A new patient is being admitted to a long-term care facility. Who has primary responsibility for each patient’s initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified? a. Physician b. Registered nur c. Nursing assista d. Licensed pract ANS: B The registered nurse (RN) has primary responsibility for each patient’s initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified. DIF: Cognitive Level: Comprehension REF: Page OBJ: 4| 10 TOP: Scope of practice KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 19. What will the nurse implement when an error is made when documenting in a patient’s chart? a. Scratch out th b. Apply correctio c. Erase the error d. Draw a single l ANS: D A nurse should not erase, apply correction fluid, or scratch out errors made while recording in a patient’s chart. Instead, the nurse should draw a single line through the error, write the word “error” above it, and sign her name or initials. DIF: Cognitive Level: Application REF: Page OBJ: 6 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 20. What should the nurse be sure to do when documenting in a patient’s chart? a. Include specul b. Chart consecu c. Leave blank sp d. Include retaliat ANS: B A nurse should not write retaliatory or critical comments about a patient or care by other health care professionals. The nurse should not leave blank spaces in the nurse’s notes. The nurse should be certain the entry is factual and not speculate or guess. The nurse should chart consecutively, line by line. DIF: Cognitive Level: Application REF: Page OBJ: 6 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 21. What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.) a. Incorrectly rec b. Failing to recor c. Charting event d. Documenting e. Marking out an ANS: A, B, C, D Marking out with a single line and initialing is an acceptable method to indicate a charting error. DIF: Cognitive Level: Application REF: Page OBJ: 4 TOP: Inadequate documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 22. When documenting an incident in the nurse’s notes, what should the nurse include? (Select all that apply.) a. Description of b. Date, time, an c. Name of physi d. Chronologic or e. Confirmation t ANS: A, B, C, D The documentation of the initiation of an incident report should not be included in the nurse’s notes. Nurse’s notes are part of the legal medical record; the incident report is not. To note that an incident report was initiated is a red flag that a problem has occurred. DIF: Cognitive Level: Application REF: Pages OBJ: 4| 6 TOP: Documenting incident reports KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 23. What are some problems associated with electronic (or computerized) charting? (Select all that apply.) a. Security b. Expense of tra c. Legibility d. Easy retrieval e. New terminolo ANS: A, B, E Security, expensive staff training, and learning new terminology are all problems of electronic charting. Legibility and easy retrieval are advantages. DIF: Cognitive Level: Comprehension REF: Pages OBJ: 1 TOP: Computer charting KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 24. What are the basic purposes of written patient records? (Select all that apply.) a. Teaching b. Legal record of c. Written comm d. Research and e. Permanent rec f. Temporary rec ANS: A, B, C, D, E There are five basic purposes for written patient records: (1) written communication, (2) permanent record for accountability, (3) legal record of care, (4) teaching, and (5) research and data collection. DIF: Cognitive Level: Comprehension REF: Page OBJ: 1 TOP: Medical record KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 25. What should a medical record provide for all health care providers? (Select all that apply.) a. Care given to t b. Care planned f c. A patient’s nur d. A patient’s me e. Details about a f. The patient’s r ANS: A, B, C, D, F A medical record should furnish all health care providers with a concise, accurate, written picture of a patient’s medical and nursing problems, care planned and given, and the patient’s response to treatments. DIF: Cognitive Level: Comprehension REF: Pages OBJ: 1 TOP: Medical record KEY: Nursing Process Step: N/A MSC: NCLEX: N/A COMPLETION 26. The best defense against malpractice claims associated with nursing care is accurate . ANS: documentation Accurate documentation can guard against malpractice claims because it should describe when, what, and how events occurred. DIF: Cognitive Level: Comprehension REF: Page OBJ: 4 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 27. Twenty-four–hour charting is designed to establish levels to help determine staffing needs. ANS: acuity Patient acuity, which is reflected in 24-hour charting compilation, can dictate staffing needs. DIF: Cognitive Level: Comprehension REF: Page OBJ: 7 TOP: 24-hour charting KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 28. Documentation using the DARE format (Data, Action, Response, Education) includes elements of the charting system. ANS: focused Focused charting uses the acronym DARE to direct and formalize charting. DIF: Cognitive Level: Comprehension REF: Page OBJ: 7 TOP: Focused charting KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 29. A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as . ANS: quality assurance, quality assessment, quality improvement Quality assurance/assessment/improvement is an audit in health care that evaluates services provided and the results achieved compared with accepted standards. DIF: Cognitive Level: Knowledge REF: Page OBJ: 1 TOP: Quality assurance/assessment/improvement KEY: Nursing Process Step: N/A MSC: NCLEX: N/A OTHER 30. A nurse is receiving a telephone order from a physician. The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals. What is the correct order of this method? 1. Read back 2. Background 3. Recommendation 4. Situation 5. Assessment ANS: D, B, E, C, A SBAR (Situation, Background, Assessment, and Recommendation) is a method of communication among health care workers and a part of documentation (Kaiser Permanente, 2007). SBAR is considered a safety measure in preventing errors from poor communication during “hand-off” or “handover” interactions, the communication that occurs from one shift to the next or when a nurse phones a health care provider with information about a patient. An additional “R” is added. The additional “R” (SBARR) represents “read back” when the nurse reads back the order for clarification. DIF: Cognitive Level: Application REF: Page OBJ: 3 TOP: SBARR KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 5: Nursing Process and Critical Thinking Cooper and Gosnell: Foundations of Nursing, 7th Edition MULTIPLE CHOICE 1. What best defines the nursing process? a. A method to e b. A series of ass c. A framework f d. A preset formu ANS: C The nursing process is a framework by which to organize individualized nursing care. DIF: Cognitive Level: Comprehension REF: Page OBJ: 1 TOP: Nursing process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment? a. 53-year-old ad b. 5-year-old adm c. 76-year-old ad d. 40-year-old ad ANS: A A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses. DIF: Cognitive Level: Application REF: Page OBJ: 2 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. What subjective data does the nurse record following a head-to-toe examination? a. Rash on back b. Prolonged nau c. Blood pressure d. White blood ce ANS: B Another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient. DIF: Cognitive Level: Application REF: Page OBJ: 3 TOP: Subjective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. What objective data should the nurse include after a patient assessment? a. Headache of 3 b. Severe stomac c. Flatulence d. Anxiety ANS: C Objective data are observable and measurable by people other than the patient. DIF: Cognitive Level: Application REF: Page OBJ: 3 TOP: Objective data Assessment KEY: Nursing Process Step: MSC: NCLEX: Physiological Integrity 5. What is classified as information provided by the family when a patient is unable to provide data during assessment? a. Primary b. Secondary c. Unreliable d. Biased ANS: B Secondary sources include family members. DIF: Cognitive Level: Comprehension REF: Page OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 6. What are the two primary methods used to collect data? a. Written report b. Review of the c. Interview and d. Review of the ANS: C The two primary methods of collecting data are interviewing and physical examination. DIF: Cognitive Level: Comprehension REF: Page OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 7. The nurse writes two nursing diagnoses: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses? a. The second dia b. The second dia c. The second dia d. The second dia ANS: D The actual nursing diagnosis represents a condition that is currently present. “Risk for” diagnoses are those that the patient is susceptible to, but not yet troubled by. DIF: Cognitive Level: Comprehension REF: Page OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. What framework does the establishment of priorities of care during the planning phase of the nursing process often use? a. Erikson’s deve b. Piaget’s cognit c. Maslow’s hiera d. Freud’s classifi ANS: C A useful framework to guide prioritization is Maslow’s hierarchy of needs. DIF: Cognitive Level: Comprehension REF: Page OBJ: 9 TOP: Priorities of care KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9. What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions? a. The patient wil b. The patient wil c. The patient wil d. The patient wil ANS: A The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within 3 days is too vague. DIF: Cognitive Level: Comprehension REF: Page OBJ: 6 TOP: Nursing diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10. What is the primary purpose of nursing orders? a. To support phy b. To provide dire c. To provide bro d. To clarify nursi ANS: B Nursing orders are necessary to provide instructions for all caregivers. DIF: Cognitive Level: Comprehension REF: Page OBJ: 7 TOP: Nursing orders KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 11. What documentation reflects implementation? a. “Patient select b. “Patient was m c. “Patient was a d. “Patient partici ANS: C Implementation is the nurse carrying out nursing orders to promote outcome achievement. DIF: Cognitive Level: Comprehension REF: Page OBJ: 2 TOP: Implementation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 12. Which nursing order is complete and correct? a. “May 10: Nursi b. “Day nurse wil Nurse” c. “Nursing assis d. “P.M. nurse wil ANS: B Nursing orders must be signed, dated, and have specific designation as to who will perform intervention and specifics about time or frequency of the intervention. DIF: Cognitive Level: Application REF: Page OBJ: 7 TOP: Nursing orders Implementation KEY: Nursing Process Step: MSC: NCLEX: Physiological Integrity 13. A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred? a. Omission b. Variance c. Failure d. Error ANS: B A variance occurs when a projected outcome is not met. DIF: Cognitive Level: Comprehension REF: Page OBJ: 8| 11 TOP: Critical pathways KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 14. During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a nursing diagnosis plan. What does this data represent? a. Symptoms b. Data clustering c. Signs of fluid o d. Urinary retenti ANS: B The nurse organizes data, and those that are related are referred to as clustering. DIF: Cognitive Level: Comprehension REF: Page OBJ: 3| 12 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 15. What type of assessment is performed continuously throughout nurse-patient contact? a. Complete b. Body systems c. Focused d. Subjective ANS: C Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan. DIF: Cognitive Level: Comprehension REF: Page OBJ: 1 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 16. What assists the nurse in the identification of nursing diagnoses? a. Objective data b. Subjective dat c. Data clustering d. Validated data ANS: C Data clustering assists the nurse in determining nursing diagnoses. DIF: Cognitive Level: Comprehension REF: Page OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 17. What organized approach might the nurse use when performing a complete physical examination? a. Maslow’s hiera b. A head-to-toe c. Subjective dat d. Objective data ANS: B A head-to-toe format provides a systematic approach. DIF: Cognitive Level: Application REF: Page OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 18. Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis? a. Physician b. LPN/LVN c. RN d. Technician ANS: C The RN is responsible for analyzing and interpreting data. DIF: Cognitive Level: Knowledge REF: Page 123 OBJ: 4 TOP: Role responsibility KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 19. What is the basis for designing and selecting nursing interventions to meet patient needs? a. Nursing diagno b. Care plan c. Physician’s ord d. Nurse’s notes ANS: A The nursing diagnosis is the basis for developing nursing interventions. DIF: Cognitive Level: Knowledge REF: Page OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 20. The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation? a. Contributing to b. A risk factor c. Difficult to mai d. A nursing resp ANS: B Risk factors are those that increase the susceptibility of a patient to a problem. DIF: Cognitive Level: Application REF: Page OBJ: 5 TOP: Risk factors KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 21. What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking? a. A syndrome nu b. An actual nurs c. A “risk for” dia d. A possible nur ANS: D A possible nursing diagnosis requires additional data to confirm a problem or to complete a data cluster so that it can be related to a NANDA-I label. DIF: Cognitive Level: Comprehension REF: Page OBJ: 4| 10 TOP: Nursing diagnosis KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 22. When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process? a. Assessment b. Planning c. Implementatio d. Evaluation ANS: B During the planning phase, the nurse connects nursing interventions to nursing orders. DIF: Cognitive Level: Comprehension REF: Page OBJ: 2 TOP: Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 23. What is an important consideration when developing the care plan? a. Ensure the nu b. Ensure the pat c. Ensure interve d. Ensure evaluat ANS: B Plans are more effective when the patient is involved in the process. The care plan is not limited in terms of the number of interventions, nor do they have to be easy. The nursing diagnoses are not evaluated; the patient’s progress toward the outcome is. DIF: Cognitive Level: Comprehension REF: Page OBJ: 6| 9 TOP: Care plan KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 24. From where are the “risk for” nursing diagnoses identified? a. The care plan b. The interventio c. The assessme d. The evaluation ANS: C Nursing diagnoses should be identified from the assessment. DIF: Cognitive Level: Knowledge REF: Page OBJ: 2 TOP: Nursing process KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 25. What expected outcome exemplifies accepted criteria? a. Nurse will asse b. Resident will o c. Resident will ta d. Nurse will mon ANS: C Expected outcomes must be patient-centered, measurable, and refer to a time frame. DIF: Cognitive Level: Application REF: Page OBJ: 6 TOP: Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data? a. The patient co b. The patient is c. The patient ex d. The patent is p ANS: A Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of nausea is an example of subjective data. All other options are examples of objective data. DIF: Cognitive Level: Application REF: Page OBJ: 1| 3 TOP: Subjective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 27. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data? a. The patient is b. The patient is c. The patient ha d. The patient sta ANS: D Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Stating “I hurt all over” is an example of subjective data. All other options are examples of objective data. DIF: Cognitive Level: Application REF: Page OBJ: 1| 3 TOP: Nursing process KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 28. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data? a. The patient is b. The patient ha c. The patient ex d. The patient co ANS: D Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of generalized discomfort is an example of subjective data. All other options are examples of objective data. DIF: Cognitive Level: Application REF: Page OBJ: 1| 3 TOP: Subjective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 29. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? a. The patient co b. The patient sta c. The patient co d. The patient is ANS: D Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Shortness of breath on exertion is an example of objective data. All other options are examples of subjective data. DIF: Cognitive Level: Application REF: Page OBJ: 1| 3 TOP: Objective data Assessment KEY: Nursing Process Step: MSC: NCLEX: Physiological Integrity 30. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? a. The patient is j b. The patient sta c. The patient co d. The patient de ANS: A Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. The patient is jaundiced is an example of objective data. All other options are examples of subjective data. DIF: Cognitive Level: Application REF: Page OBJ: 1| 3 TOP: Objective data Assessment KEY: Nursing Process Step: MSC: NCLEX: Physiological Integrity 31. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? a. The patient co b. The patient sta c. The patient co d. The patient is ANS: D Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Pacing back and forth while chanting is an example of objective data. All other options are examples of subjective data. DIF: Cognitive Level: Application REF: Page OBJ: 1| 3 TOP: Objective data Assessment KEY: Nursing Process Step: MSC: NCLEX: Physiological Integrity 32. What is an example of an appropriate nursing diagnosis? a. Impaired skin i b. Skin breakdow c. Turn patient ev d. The patient ha ANS: A “Impaired skin integrity” is an example of a nursing diagnosis. “Skin breakdown noted” is an example of a charting entry, “turn patient every 2 hours” is a nursing intervention, and “scabies” is a medical diagnosis. DIF: Cognitive Level: Comprehension REF: Pages OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 33. What is an example of an appropriate nursing diagnosis? a. Constipation b. Patient compla c. Need for laxati d. Patient has a d ANS: A Constipation is an example of a nursing diagnosis, a patient complaining of constipation is an example of a charting entry, a need for laxatives is an example of a patient need, and a patient has a duodenal ulcer is an example of a medical diagnosis. DIF: Cognitive Level: Comprehension REF: Pages OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 34. A nurse is formulating a nursing diagnosis. What is an example of an appropriately written nursing diagnosis? a. Risk for impair b. Physical immo c. Risk for impair d. Physical immo ANS: A Risk for impaired skin integrity related to physical immobilization is the only appropriately written nursing diagnosis. All other options are not listed as NANDA-I approved nursing diagnoses. DIF: Cognitive Level: Application REF: Page OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 35. Which is an example of a nursing diagnosis? a. Pneumonia b. Diabetes melli c. Impaired skin i d. Congestive he ANS: C Impaired skin integrity is the only example of a nursing diagnosis; all other options are examples of medical diagnoses. DIF: Cognitive Level: Comprehension REF: Page OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 36. Which is an example of a medical diagnosis? a. Constipation b. Diabetes melli c. Impaired skin i d. Altered nutritio ANS: B Diabetes mellitus is the only example of a medical diagnosis; all other options are examples of nursing diagnoses. DIF: Cognitive Level: Comprehension REF: Pages 126, 127 OBJ: 4 TOP: Medical diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity 37. Which is an example of a medical diagnosis? a. Pain b. Anxiety c. Pneumonia d. Impaired skin i ANS: C Pneumonia is the only example of a medical diagnosis; all other options are examples of nursing diagnoses. DIF: Cognitive Level: Comprehension REF: Pages 126, 127 OBJ: 4 TOP: Medical diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 38. Which are acceptable secondary sources for data? (Select all that apply.) a. Patient b. Family membe c. Other health p d. Diagnostic rep e. Textbooks ANS: B, C, D, E A patient is not a secondary source. The patient is the primary data source. DIF: TOP: Cognitive Level: Comprehension REF: Page Data sources KEY: Nursing Process Step: N/A OBJ: 3 MSC: NCLEX: N/A 39. a. Which are official categories of nursing diagnoses? (Select all that apply.) Actual b. Risk c. Wellness d. Syndrome e. Potential ANS: A, B, C, D Actual, risk, wellness, and syndrome are the four categories of nursing diagnoses. DIF: Cognitive Level: Comprehension REF: Page OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 40. Which are considered phases of the nursing process? (Select all that apply.) a. Diagnosis b. Prediction c. Assessment d. Evaluation e. Implementatio f. Outcome ident ANS: A, C, D, E, F The nursing process consists of six dynamic and interrelated phases: diagnosis, assessment, outcome identification, planning, implementation, and evaluation. Prediction is not a phase of the nursing process. DIF: Cognitive Level: Comprehension REF: Page OBJ: 2 TOP: Nursing process KEY: Nursing Process Step: All MSC: NCLEX: N/A COMPLETION 41. NANDA International meets to reorganize diagnosis labels and language every years. ANS: 2 NANDA meets every 2 years to revise language, form, and diagnosis labels. DIF: Cognitive Level: Knowledge REF: Pages OBJ: 10 TOP: NANDA KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 42. The standards that name and measure patient outcomes are referred to as . ANS: NOC (Nursing Outcome Classification) NOC, Nursing Outcome Classification NOC Nursing Outcome Classification NOC sets up outcome criteria based on a patient problem. DIF: Cognitive Level: Knowledge REF: Page OBJ: 10 TOP: NOC KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 43. The document that outlines a multidisciplinary plan for care interventions over a specified time frame is a . ANS: clinical pathway critical path A clinical pathway is an organized multidisciplinary plan over a specified time frame, which outlines aspects of patient care. They are also called critical paths, action plans, and care maps. DIF: Cognitive Level: Knowledge REF: Page OBJ: 11 TOP: Clinical pathways KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 44. A systematic method by which nurses plan and provide care for patients is known as the . ANS: nursing process The nursing process serves as the organizational framework for the practice of nursing. It is a systematic method by which nurses plan and provide care for patients. DIF: Cognitive Level: Knowledge REF: Page OBJ: 2 TOP: Nursing process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 45. A systemic, dynamic process by which the nurse, through interaction with the patient, significant others, and health care providers, collects and analyzes data about the patient is known as . ANS: assessment The American Nurses Association (ANA) defines assessment as “a systemic, dynamic process by which the nurse, through interaction with the client, significant others, and health care providers, collects and analyzes data about the client.” DIF: Cognitive Level: Knowledge REF: Page OBJ: 2 TOP: Nursing process KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 46. Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a . ANS: problem A problem is any health care condition that requires diagnostic, therapeutic, or educational actions. DIF: Cognitive Level: Knowledge REF: Page OBJ: 2 TOP: A problem KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 47. A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes is known as a . ANS: nursing diagnosis A nursing diagnosis is a type of health problem that can be identified. It is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. DIF: Cognitive Level: Knowledge REF: Page OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: N/A 48. The human responses to health conditions/life processes that exist in an individual, family, or community are known as a(n) . ANS: actual nursing diagnosis An actual nursing diagnosis is described as the human responses to health conditions/life processes that exist in an individual, family, or community. DIF: Cognitive Level: Knowledge REF: Page OBJ: 4 TOP: Actual nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: N/A 49. Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) . ANS: risk nursing diagnosis A risk nursing diagnosis is defined as the human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community. DIF: Cognitive Level: Knowledge REF: Page OBJ: 4 TOP: Risk nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: N/A 50. Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a . ANS: wellness nursing diagnosis A wellness nursing diagnosis is defined as human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. DIF: Cognitive Level: Knowledge REF: Page OBJ: 4 TOP: Wellness nursing diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: N/A 51. The identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures is known as a . ANS: medical diagnosis A medical diagnosis is the identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures. DIF: Cognitive Level: Knowledge REF: Page OBJ: 4 TOP: Medical diagnosis KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 52. A health care system that provides control over health care services for a specific group of individuals in an attempt to control cost is known as . ANS: managed care Managed care is a health care system that provides control over health care services for a specific group of individuals in attempts to control cost. DIF: Cognitive Level: Knowledge REF: Page OBJ: 6| 11 TOP: Risk Managed care KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 53. A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases is known as a . ANS: critical pathway A critical pathway is a multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases. DIF: Cognitive Level: Knowledge REF: Page OBJ: 11 TOP: Clinical pathways KEY: Nursing Process Step: N/A MSC: NCLEX: N/A