1ST EDITION LUU KAYINGO’STEST BANK
,CH 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 patients mental status
• Exploring patient responses to health problems
PRECISE ANSWER:-D
REASONING:->>> A nursing assessment is done to identify the patients
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 identifyingmedical conditions is not part of the nursing process.
Determining the patients mental status is one part of the nursing assessment,
but it is not the primary purpose.
DIFFICULT: Cognitive Level:
ComprehensionREF: dm 36 OBJ: 1 | 3
TOPIC: Nursing Process Step:
Assessment
MSC: NCLEX Patient 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
PRECISE ANSWER:-B
REASONING:->>> 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 arenot part of the scope of NANDA I.
,DIFFICULT: Cognitive Level:
KnowledgeREF: pp. 37-38 OBJ: 5
TOPIC:
Nursing Process Step: Diagnosis
MSC: NCLEX Patient Needs Category: Physiological Integrity
• Which task is included in the assessment step of the nursing process?
• Establishing patient goals/outcomes
• Implementing the nursing care plan (NCP)
• Measuring goal/outcome achievement
• Collecting and communicating data
PRECISE ANSWER:-D
REASONING:->>> Data are collected and communicated in the
assessment phase of thenursing process. Establishing goals is the
function of planning.
Implementing the NCP is the function of implementation. Measuring
outcome achievement is the function of evaluation.
DIFFICULT: Cognitive Level:
ComprehensionREF: dm 36 OBJ: 2 | 3
TOPIC: Nursing Process Step:
Assessment
MSC: NCLEX Patient 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 patient problems that professional nurses treat.
• Nursing diagnoses identify causes related to illness.
PRECISE ANSWER:-C
REASONING:->>> Diagnostic statements identify problems a professional
nurse is independently able totreat within the scope of professional
practice. Nursing diagnoses vary with the changing condition of the patient.
The response patterns are unique to the patient and are not disease
specific. Nursing diagnoses describe the patients human response pattern.
DIFFICULT: Cognitive Level: Comprehension
, REF: pp. 37-38 OBJ: 5 TOPIC: Nursing
Process Step: Diagnosis
MSC: NCLEX Patient 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
PRECISE ANSWER:-B
REASONING:->>> 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 patient.
Standardized terminology assists practitioners in the implementation of the
five phases of the nursingprocess. Classification systems are not related to
disease process and are not used for financial purposes. Classification
systems include interventions for all health conditions.
DIFFICULT: Cognitive Level: Knowledge
REF: dm 34 OBJ: 11 TOPIC: Nursing
Process Step: Implementation
MSC: NCLEX Patient Needs Category: Safe, Effective Care Environment
• Which type of nursing diagnosis will be written when the patient
exhibits factors that makes him or her susceptible to the
development of a problem?
• Actual diagnosis
• Risk diagnosis
• Possible diagnosis
• Wellness diagnosis
PRECISE ANSWER:-B
REASONING:->>> When patients have the potential or risk for a problem
to develop, a risk diagnosis is written. These diagnoses are two part
statements such as Riskfor 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