Nursing Process (Fundamentals of Success)
When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of the patient?
A: Reassess the patient
B: Examine the related to factors
C: Analyze the secondary to factors
D: Review the defining characteristics - Answer- D: REVIEW THE DEFINING CHARACTERS--The first thing the nurse should do to differentiate between two closely associated nursing diagnoses is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.
The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to:
A: Diagnose if the patient is at risk for falls. B: Ensure that the patient's skin is intact
C: Establish a therapeutic relationship
D: Identify important data - Answer- D: IDENTIFY IMPORTANT DATA--This is the primary purpose of a nursing admission assessment. Data must be collected and then analyzed to determine significance, and grouped in meaningful clusters before a nursing diagnosis can be made.
The nurse identifies that the patient statement that provides subjective data is: A: "I'm not sure that I am going to be able to manage at home by myself."
B: "I can call a home-care agency if I feel I need help at home."
C: "What should I do if I have uncontrollable pain at home?"
D: "Will a home health aide help me with my care at home?" - Answer- A: "I'm not sure that i am going to be able to manage at home by myself." -- This is subjective information because it is the patient's perception and can be verified only by the patient. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm.
The nurse understands that evaluation most directly relates to which aspect of the Nursing Process?
A: Goal
B: Problem
C: Etiology
D: Implementation - Answer- A: Goal-- To evaluate the effectiveness of a nursing action, the nurse needs to compare the actual patient outcome with the expected patient outcome. The expected outcomes are the measurable data that reflect goal achievement, and the actual outcomes are what really happened.
The nurse comes to the conclusion that a patient's elevated temperature, pulse, and respirations are significant. What step of the Nursing Process is being used when the
nurse comes to this conclusion? A: Implementation
B: Assessment
C: Evaluation
D: Diagnosis - Answer- D: Diagnosis-- During the diagnosis step of the Nursing Process, data are critically analyzed and interpreted; significance of data is determined; inferences are made and validated; cues and clusters of cues are compared with the defining characteristics of nursing diagnoses; contributing factors are identified; and nursing diagnoses are identified and organized in order of priority.
When the nurse considers the Nursing Process, the word "identify" is to "recognize" as the word "do" is to:
A: Plan
B: Evaluate
C: Diagnose
D: Implement - Answer- D: Implement-- This is the correct analogy. The words identify and recognize have the same definition. They both mean the same as that which is known. The words do and implement both have the same definition. They both mean to carry out some action.
The nurse is collecting data associated with a patient's anxiety. Which assessment method should be used to collect this information? A: Observing
B: Inspecting
C: Auscultation
D: Interviewing - Answer- D: Interviewing--- Interviewing a patient is the most effecting data collection method when collecting subjective data associated with a patient's anxiety. The patient is the primary source for subjective data about beliefs, values, feelings, perception, fears, and concerns.
Which nursing action reflects an activity associated with the diagnosis step of the Nursing Process?
A: Formulating a plan of care
B: Identifying the patient's potential risks
C: Designing ways to minimize a patient's stressors D: Making decisions about the effectiveness of patient care - Answer- B: Identify the patient's potential risks-- Potential risk factors are identified during the diagnosis step
of the Nursing Process. Risk diagnoses are designed to address situation where patients have particular vulnerability to health problems.
The nurse collects objective data when a hospitalized patient states:
A: "I am hungry."
B: "I feel very warm."
C: "I ate half my lunch."
D: "I have an urge to urinate." - Answer- C: "I ate half my lunch."-- The amount of food eaten by a patient can be objectively verified. The nurse measures and documents the percentage of a meal ingested by a patient to quantify the amount of food consumed.
The nurse understands that subjective data has been obtained when the patient states:
When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of the patient?
A: Reassess the patient
B: Examine the related to factors
C: Analyze the secondary to factors
D: Review the defining characteristics - Answer- D: REVIEW THE DEFINING CHARACTERS--The first thing the nurse should do to differentiate between two closely associated nursing diagnoses is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.
The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to:
A: Diagnose if the patient is at risk for falls. B: Ensure that the patient's skin is intact
C: Establish a therapeutic relationship
D: Identify important data - Answer- D: IDENTIFY IMPORTANT DATA--This is the primary purpose of a nursing admission assessment. Data must be collected and then analyzed to determine significance, and grouped in meaningful clusters before a nursing diagnosis can be made.
The nurse identifies that the patient statement that provides subjective data is: A: "I'm not sure that I am going to be able to manage at home by myself."
B: "I can call a home-care agency if I feel I need help at home."
C: "What should I do if I have uncontrollable pain at home?"
D: "Will a home health aide help me with my care at home?" - Answer- A: "I'm not sure that i am going to be able to manage at home by myself." -- This is subjective information because it is the patient's perception and can be verified only by the patient. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm.
The nurse understands that evaluation most directly relates to which aspect of the Nursing Process?
A: Goal
B: Problem
C: Etiology
D: Implementation - Answer- A: Goal-- To evaluate the effectiveness of a nursing action, the nurse needs to compare the actual patient outcome with the expected patient outcome. The expected outcomes are the measurable data that reflect goal achievement, and the actual outcomes are what really happened.
The nurse comes to the conclusion that a patient's elevated temperature, pulse, and respirations are significant. What step of the Nursing Process is being used when the
nurse comes to this conclusion? A: Implementation
B: Assessment
C: Evaluation
D: Diagnosis - Answer- D: Diagnosis-- During the diagnosis step of the Nursing Process, data are critically analyzed and interpreted; significance of data is determined; inferences are made and validated; cues and clusters of cues are compared with the defining characteristics of nursing diagnoses; contributing factors are identified; and nursing diagnoses are identified and organized in order of priority.
When the nurse considers the Nursing Process, the word "identify" is to "recognize" as the word "do" is to:
A: Plan
B: Evaluate
C: Diagnose
D: Implement - Answer- D: Implement-- This is the correct analogy. The words identify and recognize have the same definition. They both mean the same as that which is known. The words do and implement both have the same definition. They both mean to carry out some action.
The nurse is collecting data associated with a patient's anxiety. Which assessment method should be used to collect this information? A: Observing
B: Inspecting
C: Auscultation
D: Interviewing - Answer- D: Interviewing--- Interviewing a patient is the most effecting data collection method when collecting subjective data associated with a patient's anxiety. The patient is the primary source for subjective data about beliefs, values, feelings, perception, fears, and concerns.
Which nursing action reflects an activity associated with the diagnosis step of the Nursing Process?
A: Formulating a plan of care
B: Identifying the patient's potential risks
C: Designing ways to minimize a patient's stressors D: Making decisions about the effectiveness of patient care - Answer- B: Identify the patient's potential risks-- Potential risk factors are identified during the diagnosis step
of the Nursing Process. Risk diagnoses are designed to address situation where patients have particular vulnerability to health problems.
The nurse collects objective data when a hospitalized patient states:
A: "I am hungry."
B: "I feel very warm."
C: "I ate half my lunch."
D: "I have an urge to urinate." - Answer- C: "I ate half my lunch."-- The amount of food eaten by a patient can be objectively verified. The nurse measures and documents the percentage of a meal ingested by a patient to quantify the amount of food consumed.
The nurse understands that subjective data has been obtained when the patient states:
