1st Edition Luu, Kayingo, and Hass
,Chapter 1: An Introduction to Evidence-Based Clinical Practice Guidelines
MULTIPLE CHOICE
• What is the primary purpose of the nursing assessment?
• Identifying underlying pathologic conditions
• Assisting the physician in identifying medical conditions
• Determining the clients mental status
• Exploring client responses to health problems
RIGHT CHOICE✔✔ D
A nursing assessment is done to identify the clients response to health
problems. During the nursing assessment phase, a comprehensive
information base is developed through a physical examination, nursing
history, medication history, and professional observation. Identifying
underlying pathologic conditions and assisting the physician in identifying
medical conditions is not part of the nursing process. Determining the
clients mental status is one part of the nursing assessment, but it is not
the primary purpose.
DIF: Cognitive Level: Comprehension
REF: dm 36 OBJ: 1 | 3 TOP: Nursing
Process Step: Assessment
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
• What is the basis of the NANDA I taxonomy?
• Functional health patterns
• Human response patterns
• Basic human needs
• Pathophysiologic needs
RIGHT CHOICE✔✔ B
The NANDA I taxonomy identifies human response patterns.
Functional components of health patterns are limited to activity, fluid
volume, nutrition, self care, and sensory perception. Basic human needs
comprise less than merely health patterns. Pathophysiologic needs are
not part of the scope of NANDA I.
,DIF: Cognitive Level: Knowledge
REF: pp. 37-38 OBJ: 5 TOP:
Nursing Process Step: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity
• Which task is included in the assessment step of the nursing process?
• Establishing client goals/outcomes
• Implementing the nursing care plan (NCP)
• Measuring goal/outcome achievement
• Collecting and communicating data
RIGHT CHOICE✔✔ D
Data are collected and communicated in the assessment phase of the
nursing process. Establishing goals is the function of planning.
Implementing the NCP is the function of implementation. Measuring
outcome achievement is the function of evaluation.
DIF: Cognitive Level: Comprehension
REF: dm 36 OBJ: 2 | 3 TOP: Nursing
Process Step: Assessment
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
• Which statement regarding nursing diagnoses is accurate?
• Nursing diagnoses remain the same for as long as the disease is present.
• Nursing diagnoses are written to identify disease states.
• Nursing diagnoses describe client problems that nurses treat.
• Nursing diagnoses identify causes related to illness.
RIGHT CHOICE✔✔ C
Diagnostic statements identify problems a nursing practitioner is
independently able to treat within the scope of professional practice.
Nursing diagnoses vary with the changing condition of the client. The
response patterns are unique to the client and are not disease specific.
Nursing diagnoses describe the clients human response pattern.
DIF: Cognitive Level: Comprehension
, REF: pp. 37-38 OBJ: 5 TOP: Nursing
Process Step: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity
• What do the classification systems NIC and NOC provide?
• Individualized data banks of treatments related to disease processes
• Standardized language for reporting and analyzing nursing care delivery
• A measure for cost containment within medical institutions
• Specialized interventions for rare diseases
RIGHT CHOICE✔✔ B
Nursing classification systems such as NIC and NOC are designed to
provide a standardized language for reporting and analyzing nursing care
delivery that is individualized for each client. Standardized terminology
assists practitioners in the implementation of the five phases of the nursing
process. Classification systems are not related to disease process and are
not used for financial purposes. Classification systems include
interventions for all health conditions.
DIF: Cognitive Level: Knowledge
REF: dm 34 OBJ: 11 TOP: Nursing
Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
• Which type of nursing diagnosis will be written when the client
exhibits factors that makes him or her susceptible to the
development of a problem?
• Actual diagnosis
• Risk diagnosis
• Possible diagnosis
• Wellness diagnosis
RIGHT CHOICE✔✔ B
When clients have the potential or risk for a problem to develop, a risk
diagnosis is written. These diagnoses are two part statements such as Risk
for falls related to unsteady gait. An actual diagnosis consists of a
NANDA diagnostic label, contributing factor (if known), and defining
characteristics such as signs and symptoms. A possible nursing diagnosis