Chapter 05 Assessment, Nursing Diagnosis, and Planning

Chapter 05: Assessment, Nursing Diagnosis, and Planning



MULTIPLE CHOICE

1. When the patient complains of nausea and dizziness, the nurse recognizes these complaints as
data.
a. objective
b. medical
c. subjective
d. adjunct
ANS: C
Subjective data are symptoms that only the patient can identify.

DIF: Cognitive Level: Application REF: p. 58 OBJ: Theory #3
TOP: Assessment Data KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

2. The major goal of the admission interview (usually performed by the RN) is to:
a. establish rapport.
b. help the patient understands the objectives of care.
c. identify the patient’s major complaints.
d. initiate nursing care plan forms.
ANS: C
The interview is used as part of thNe UaR
ssSeIsNsGmTeBn.C
t pOrM
ocess to elicit information about the patient’s
physical, emotional, and spiritual health.

DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #1
TOP: Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A

3. An example of a structured format for gathering data that aids in forming a database is:
a. North American Nursing Diagnosis Association–International (NANDA-I).
b. Maslow’s hierarchy.
c. QSENl
d. Gordon’s 11 Health Patterns.
ANS: D
Mary Gordon’s assessment guide is a guided path to cover 11 health points. Although Maslow
may be used, it is not structured.

DIF: Cognitive Level: Knowledge REF: p. 58|Box 5-1
OBJ: Theory # 2 TOP: Gordon’s 11 Health Patterns KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

4. During the assessment phase of the nursing process, the nurse:
a. develops a care plan to meet the patient’s nursing needs.
b. begins to formulate plans for providing nursing intervention.
c. establishes a nursing diagnosis for the nursing care plan.
d. gathers, organizes, and documents data in a logical database.

, ANS: D
Gathering and organizing data is the first step in the assessment phase of the nursing process.

DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #1
TOP: Data Collection KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A

5. After the admission assessment is completed, on subsequent shifts or days, the nurse:
a. does not assess the patient again unless the condition changes.
b. refers only to the admission assessment during the hospitalization.
c. performs a complete physical examination every day.
d. assesses the patient briefly in the first hour of the shift.
ANS: D
The patient should be briefly assessed at the beginning of each shift and more thoroughly if
his or her condition changes or as per the plan of care.

DIF: Cognitive Level: Comprehension REF: p. 70 OBJ: Theory #1
TOP: Physical Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

6. The nurse performing an admission interview on an older adult person should:
a. rush through the interview to avoid tiring the patient.
b. direct questions to the family rather than the patient.
c. allow more time for a response to questions.
d. prompt the patient to speed recall.
ANS: C NURSINGTB.COM
When interviewing an older adult person, allow more time because the person will probably
have a more extensive history and may take a little longer to recall the needed information.

DIF: Cognitive Level: Application REF: p. 59 OBJ: Theory #5
TOP: Admission Interview KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

7. A nursing diagnosis consists of:
a. the health care provider’s medical diagnosis listed as the nursing diagnosis.
b. diagnostic labels formulated by the North American Nursing Diagnosis
Association–International (NANDA-I).
c. the patient’s explanation of his or her “chief complaint” or “current complaint.”
d. the results of the nursing assessment without consideration of doctor’s orders.

ANS: B
NANDA-I has formulated an official list of nursing diagnoses to identify patient problems and
problems that patients are at risk of developing. A nursing diagnosis is independent of a
medical diagnosis.

DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: Theory #5
TOP: Nursing Diagnosis KEY: Nursing Process Step: Planning
MSC: NCLEX: N/A