1st Edition Luu, Kayingo, and Hass
, Chapter 1: An Introduction to Evidence-Based Clinical Practice Guidelines
MULTIPLE CHOICE
1. What is the primary goal of the nursing assessment?
A. To identify underlying medical conditions
B. To assist the physician in diagnosing diseases
C. To assess the patient's mental status
D. To evaluate the patient’s response to health concerns
Correct Answer: D
Rationale: The purpose of a nursing assessment is to determine how the patient responds
physically, emotionally, and mentally to health problems.
2. What is the foundation of the NANDA-I taxonomy?
A. Functional health patterns
B. Human response patterns
C. Basic human needs
D. Pathophysiologic processes
Correct Answer: B
Rationale: NANDA-I is based on human responses, which guide nurses in forming nursing
diagnoses.
3. Which task is a key part of the assessment phase of the nursing process?
A. Setting patient-centered goals
B. Carrying out the nursing care plan
C. Measuring whether goals were achieved
D. Collecting and communicating patient data
Correct Answer: D
,Rationale: Data collection and communication are essential components of the assessment phase.
4. Which statement best describes a nursing diagnosis?
A. It remains the same as long as the disease is present
B. It is used to diagnose medical conditions
C. It describes patient problems that nurses can address independently
D. It focuses on the cause of illness
Correct Answer: C
Rationale: Nursing diagnoses are based on patient responses that nurses are licensed to manage.
5. What is the primary function of the NIC and NOC systems?
A. To provide individualized treatment plans for illnesses
B. To offer standardized language for documenting nursing care
C. To help reduce healthcare costs
D. To target interventions for rare diseases
Correct Answer: B
Rationale: These systems promote consistency in planning and evaluating nursing interventions.
6. What type of nursing diagnosis is made when a patient is vulnerable to developing a problem?
A. Actual diagnosis
B. Risk diagnosis
C. Possible diagnosis
D. Wellness diagnosis
Correct Answer: B
Rationale: A risk diagnosis identifies a potential issue based on risk factors present in the patient.
, 7. Which of the following is an appropriate patient outcome statement?
A. Patient will express acceptance of breast loss after surgery
B. Patient will die with dignity
C. Nurse will assess patient comfort at shift’s end
D. Within 8 hours, urine output will be more than 30 mL/hr
Correct Answer: D
Rationale: This statement is specific, measurable, and time-bound.
8. Which is an example of an interdependent nursing action?
A. Assess breath sounds every 4 hours
B. Educate the patient on medication use
C. Administer Demerol 50 mg IM every 4 hours PRN
D. Encourage the patient to express emotions
Correct Answer: C
Rationale: PRN medication requires a provider’s order and nurse’s judgment, making it
interdependent.
9. Who is the most reliable source of information when obtaining a patient history?
A. The physician
B. The patient’s medical record
C. The patient’s family
D. The patient
Correct Answer: D
Rationale: The patient is the primary source unless they are unable to provide information.