Chapter 1: An Introduction to Evidence-Based Clinical Practice Guidelines
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MULTIPLE CHOICE ft
• What is the primary purpose of the nursing assessment?
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• Identifying underlying pathologic conditions ft ft ft
• Assisting the physician in identifying medical conditions ft ft ft ft ft ft
• Determining the patients mental status ft ft ft ft
• Exploring patient responses to health problems ft ft ft ft ft
ANS: D ft
A nursing assessment is done to identify the patients response to health
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problems. During the nursing assessment phase, a comprehensive
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information base is developed through a physical examination, nursing
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history, medication history, and professional observation. Identifying
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underlying pathologic conditions and assisting the physician in identifying
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medical conditions is not part of the nursing process. Determining the
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patients mental status is one part of the nursing assessment, but it is not the
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primary purpose.
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DIF: Cognitive Level: Comprehension
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REF: dm 36 OBJ: 1 | 3 TOP: Nursing
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Process Step: Assessment
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MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
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• What is the basis of the NANDA I taxonomy?
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• Functional health patterns ft ft
• Human response patterns ft ft
• Basic human needs ft ft
• Pathophysiologic needs ft
ANS: B ft
The NANDA I taxonomy identifies human response patterns. Functional
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components of health patterns are limited to activity, fluid volume,
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nutrition, self care, and sensory perception. Basic human needs comprise
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less than merely health patterns. Pathophysiologic needs are not part of
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the scope of NANDA I.
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,DIF: Cognitive Level: Knowledge REF:
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pp. 37-38 OBJ: 5 TOP:
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Nursing Process Step: Diagnosis ft ft ft
MSC: NCLEX Client Needs Category: Physiological Integrity
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• Which task is included in the assessment step of the nursing process?
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• Establishing patient goals/outcomes ft ft
• Implementing the nursing care plan (NCP) ft ft ft ft ft
• Measuring goal/outcome achievement ft ft
• Collecting and communicating data ft ft ft
ANS: D ft
Data are collected and communicated in the assessment phase of the nursing
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process. Establishing goals is the function of planning.
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Implementing the NCP is the function of implementation. Measuring ft ft ft ft ft ft ft ft
outcome achievement is the function of evaluation.
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DIF: Cognitive Level: Comprehension
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REF: dm 36 OBJ: 2 | 3 TOP: Nursing
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Process Step: Assessment
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MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
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• Which statement regarding nursing diagnoses is accurate?
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• Nursing diagnoses remain the same for as long as the disease is present.
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• Nursing diagnoses are written to identify disease states. ft ft ft ft ft ft ft
• Nursing diagnoses describe patient problems that nurses treat. ft ft ft ft ft ft ft
• Nursing diagnoses identify causes related to illness. ft ft ft ft ft ft
ANS: C ft
Diagnostic statements identify problems a nurse is independently able to
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treat within the scope of professional practice. Nursing diagnoses vary
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with the changing condition of the patient. The response patterns are
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unique to the patient and are not disease specific. Nursing diagnoses
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describe the patients human response pattern.
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DIF: Cognitive Level: Comprehension
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, REF: pp. 37-38 OBJ: 5 TOP: Nursing
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Process Step: Diagnosis ft ft
MSC: NCLEX Client Needs Category: Physiological Integrity
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• What do the classification systems NIC and NOC provide?
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• Individualized data banks of treatments related to disease processes ft ft ft ft ft ft ft ft
• Standardized language for reporting and analyzing nursing care delivery ft ft ft ft ft ft ft ft
• A measure for cost containment within medical institutions
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• Specialized interventions for rare diseases ft ft ft ft
ANS: B ft
Nursing classification systems such as NIC and NOC are designed to
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provide a standardized language for reporting and analyzing nursing care
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delivery that is individualized for each patient. Standardized terminology
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assists practitioners in the implementation of the five phases of the nursing
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process. Classification systems are not related to disease process and are
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not used for financial purposes. Classification systems include
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interventions for all health conditions.
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DIF: Cognitive Level: Knowledge
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REF: dm 34 OBJ: 11 TOP: Nursing
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Process Step: Implementation
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MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
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• Which type of nursing diagnosis will be written when the
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patient exhibits factors that makes him or her susceptible to the
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development of a problem?
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• Actual diagnosis ft
• Risk diagnosis ft
• Possible diagnosis ft
• Wellness diagnosis ft
ANS: B ft
When patients have the potential or risk for a problem to develop, a risk
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diagnosis is written. These diagnoses are two part statements such as Risk
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for falls related to unsteady gait. An actual diagnosis consists of a
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NANDA diagnostic label, contributing factor (if known), and defining
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characteristics such as signs and symptoms. A possible nursing diagnosis
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