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Assessment Steps, Diagnostic Processes & Nursing Models: Complete ()

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Assessment Steps, Diagnostic Processes &
Nursing Models: Complete (2025-2026)


SECTION A: MULTIPLE CHOICE QUESTIONS .

1. What is the first step of the nursing process?
a) Planning
b) Implementation
c) Assessment
d) Evaluation

Answer: c) Assessment
Rationale: Assessment is the systematic collection of patient data, which forms the
foundation for all subsequent steps of the nursing process (ADPIE).

2. Which type of data is measurable and observable?
a) Subjective
b) Objective
c) Intuitive
d) Historical

Answer: b) Objective
Rationale: Objective data includes vital signs, lab results, physical exam findings. Subjective
data comes from the patient’s experience (e.g., pain level described as “severe”).

3. During which phase of the nursing process does the nurse identify patient problems?
a) Assessment
b) Diagnosis
c) Planning
d) Implementation

Answer: b) Diagnosis
Rationale: Nursing diagnosis is the clinical judgment about individual, family, or community
responses to actual or potential health problems.

4. The NANDA-I taxonomy is used for:
a) Medical diagnoses
b) Nursing diagnoses
c) ICD codes
d) Reimbursement

,Answer: b) Nursing diagnoses
Rationale: NANDA International (NANDA-I) provides standardized nursing diagnosis
terminology.

5. A patient says, “I feel anxious.” This is an example of:
a) Objective data
b) Subjective data
c) Secondary data
d) Environmental data

Answer: b) Subjective data
Rationale: Subjective data comes directly from the patient’s own feelings, perceptions, or
statements.

6. Which nursing model focuses on self-care deficits?
a) Roy Adaptation Model
b) Orem’s Self-Care Deficit Theory
c) Neuman Systems Model
d) Watson’s Caring Theory

Answer: b) Orem’s Self-Care Deficit Theory
Rationale: Orem’s model emphasizes the patient’s ability to perform self-care activities.

7. In the diagnostic process, a “risk for” nursing diagnosis:
a) Indicates an existing problem
b) Indicates vulnerability to developing a problem
c) Is a medical diagnosis
d) Requires no intervention

Answer: b) Indicates vulnerability to developing a problem
Rationale: Risk diagnoses (e.g., Risk for Falls) describe potential vulnerabilities.

8. Which step follows data clustering in diagnostic reasoning?
a) Data collection
b) Identifying patterns
c) Formulating the nursing diagnosis
d) Evaluation

Answer: c) Formulating the nursing diagnosis
Rationale: After clustering data into meaningful patterns, the nurse selects an appropriate
NANDA-I label.

9. The Roy Adaptation Model focuses on:
a) Self-care
b) Adaptation to environmental stimuli

, c) Unitary human beings
d) Interpersonal relations

Answer: b) Adaptation to environmental stimuli
Rationale: Roy’s model views the person as an adaptive system responding to
internal/external stimuli.

10. A nurse measures blood pressure. This is part of:
a) Nursing diagnosis
b) Assessment
c) Implementation
d) Evaluation

Answer: b) Assessment
Rationale: Physical examination and vital signs are objective assessment activities.

11. Which of the following is a correct nursing diagnosis statement?
a) Pneumonia
b) Ineffective Airway Clearance related to retained secretions
c) Congestive heart failure
d) Asthma exacerbation

Answer: b) Ineffective Airway Clearance related to retained secretions
Rationale: Nursing diagnoses use NANDA-I labels; medical diagnoses are different.

12. The “PES” format stands for:
a) Problem, Evaluation, Solution
b) Problem, Etiology, Signs/Symptoms
c) Planning, Execution, Supervision
d) Patient, Environment, Symptoms

Answer: b) Problem, Etiology, Signs/Symptoms
Rationale: PES is standard for writing nursing diagnoses: Problem (diagnostic label), Etiology
(related factors), Signs/Symptoms (defining characteristics).

13. In the Neuman Systems Model, the “lines of resistance” are:
a) Prevention levels
b) Internal factors protecting against stressors
c) Nursing interventions
d) Evaluation criteria

Answer: b) Internal factors protecting against stressors
Rationale: Lines of resistance are activated when stressors penetrate the normal line of
defense.

Información del documento

Subido en
18 de abril de 2026
Número de páginas
21
Escrito en
2025/2026
Tipo
Examen
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