Revision Questions with Verified Explanations
What best defines the nursing process?
A Method to ensure that the physicians orders are implemented correctly.
A series of assessments that isolate a patients health problem.
A framework for the organization of individualized nursing care.
A preset formula for the design of nursing care. - Answer A framework for the organization of
individualized nursing care.
All of the following patients have been admitted to the acute care setting. On admission, which patient
should receive a focused assessment?
53-year-old admitted with a perforated ulcer
5-year-old admitted for the implant of grommets in the middle ear
76-year-old admitted for a knee replacement
40-year-old admitted for possible bowel obstruction - Answer 53-year-old admitted with a perforated
ulcer
What subjective data does the nurse record following a head-to-toe examination?
Rash on back
,Prolonged nausea
Blood pressure of 190/100
White blood cell count of 19,000 - Answer Prolonged nausea
What objective data should the nurse include after a patient assessment?
Headache of 3 days duration
Severe stomach cramps
Flatulence
Anxiety - Answer Flatulence
What is classified as information provided by the family when a patient is unable to provide data during
assessment?
Primary
Secondary
Unreliable
Biased - Answer Secondary
What are the two primary methods used to collect data?
Written report by patient and family
Review of the chart and the nurses notes
Interview and physical examination
, Review of the physicians orders and the Kardex - Answer Interview and physical examination
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?
The second diagnosis needs no defined nursing interventions.
The second diagnosis needs medical intervention.
The second diagnosis will not need to be evaluated.
The second diagnosis reflects a problem that does not yet exist. - Answer The second diagnosis reflects a
problem that does not yet exist.
What framework does the establishment of priorities of care during the planning phase of the nursing
process often use?
Eriksons developmental tasks
Piagets cognitive table
Maslows hierarchy of needs
Freuds classifications - Answer Maslows hierarchy of needs
What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway
clearance related to thick secretions?
The patient will increase intake to 1000 mL daily to liquefy secretions.