Chapter 05: Nursing Process and Critical Thinking
Cooper: Foundation of Nursing
MULTIPLE CHOICE
1. What best defines the nursing process?
a. A method to ensure that the health care provider’s orders are implemented
correctly.
b. A series of assessments that isolate a patient’s health problem.
c. A framework for the organization of individualized nursing care.
d. A preset formula for the design of nursing care.
ANS: C
The nursing process is a framework by which to organize individualized nursing care.
DIF: Cognitive Level: Comprehension REF: p. 80 OBJ: 1
TOP: Nursing process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. All of the following patients have been admitted to the acute care setting. On admission,
which patient should receive a focused assessment?
a.53-year-old admitted with a perforated ulcer
b.5-year-old admitted for the implant of grommets in the middle ear
c.76-year-old admitted for a knee replacement
d.40-year-old admitted for possible bowel obstruction
ANS: A
A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should
receive a focused assessment. The remaining options are not considered critical illnesses.
DIF: Cognitive Level: Application REF: p. 81 | p. 82 OBJ: 2
TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3. What subjective data does the nurse record following a head-to-toe examination?
a. Rash on back
b. Prolonged nausea
c. Blood pressure of 190/100
d. White blood cell count of 19,000
ANS: B
Another term for subjective data is symptoms, which cannot be observed or measured. This
data must come from the patient.
DIF: Cognitive Level: Application REF: p. 82 OBJ: 3
TOP: Subjective data KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
4. What objective data should the nurse include after a patient assessment?
a. Headache of 3 days’ duration
b. Severe stomach cramps
, c. Flatulence
d. Anxiety
ANS: C
Objective data are observable and measurable by people other than the patient.
DIF: Cognitive Level: Application REF: p. 82 OBJ: 3
TOP: Objective data KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. When the nurse is prioritizing care during the planning phase of the nursing process, what is
the guiding framework?
a. Primary
b. Secondary
c. Unreliable
d. Biased
ANS: B
Secondary sources include family members.
DIF: Cognitive Level: Comprehension REF: p. 82 OBJ: 3
TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
6. What are the two primary methods used to collect data?
a. Written report by patient and family
b. Review of the chart and the nurse’s notes
c. Interview and physical examination
d. Review of the health care provider’s orders and the Kardex
ANS: C
The two primary methods of collecting data are interviewing and physical examination.
DIF: Cognitive Level: Comprehension REF: p. 82 OBJ: 3
TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
7. The nurse writes two patient problems: (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?
a. The second diagnosis needs no defined nursing interventions.
b. The second diagnosis needs medical intervention.
c. The second diagnosis will not need to be evaluated.
d. The second diagnosis reflects a problem that does not yet exist.
ANS: D
The actual patient problem represents a condition that is currently present. “Risk for”
diagnoses are those that the patient is susceptible to, but not yet troubled by.
DIF: Cognitive Level: Comprehension REF: p. 84 OBJ: 4
TOP: Patient problem KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
8. What framework does the establishment of priorities of care during the planning phase of the
nursing process often use?
Cooper: Foundation of Nursing
MULTIPLE CHOICE
1. What best defines the nursing process?
a. A method to ensure that the health care provider’s orders are implemented
correctly.
b. A series of assessments that isolate a patient’s health problem.
c. A framework for the organization of individualized nursing care.
d. A preset formula for the design of nursing care.
ANS: C
The nursing process is a framework by which to organize individualized nursing care.
DIF: Cognitive Level: Comprehension REF: p. 80 OBJ: 1
TOP: Nursing process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. All of the following patients have been admitted to the acute care setting. On admission,
which patient should receive a focused assessment?
a.53-year-old admitted with a perforated ulcer
b.5-year-old admitted for the implant of grommets in the middle ear
c.76-year-old admitted for a knee replacement
d.40-year-old admitted for possible bowel obstruction
ANS: A
A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should
receive a focused assessment. The remaining options are not considered critical illnesses.
DIF: Cognitive Level: Application REF: p. 81 | p. 82 OBJ: 2
TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3. What subjective data does the nurse record following a head-to-toe examination?
a. Rash on back
b. Prolonged nausea
c. Blood pressure of 190/100
d. White blood cell count of 19,000
ANS: B
Another term for subjective data is symptoms, which cannot be observed or measured. This
data must come from the patient.
DIF: Cognitive Level: Application REF: p. 82 OBJ: 3
TOP: Subjective data KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
4. What objective data should the nurse include after a patient assessment?
a. Headache of 3 days’ duration
b. Severe stomach cramps
, c. Flatulence
d. Anxiety
ANS: C
Objective data are observable and measurable by people other than the patient.
DIF: Cognitive Level: Application REF: p. 82 OBJ: 3
TOP: Objective data KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. When the nurse is prioritizing care during the planning phase of the nursing process, what is
the guiding framework?
a. Primary
b. Secondary
c. Unreliable
d. Biased
ANS: B
Secondary sources include family members.
DIF: Cognitive Level: Comprehension REF: p. 82 OBJ: 3
TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
6. What are the two primary methods used to collect data?
a. Written report by patient and family
b. Review of the chart and the nurse’s notes
c. Interview and physical examination
d. Review of the health care provider’s orders and the Kardex
ANS: C
The two primary methods of collecting data are interviewing and physical examination.
DIF: Cognitive Level: Comprehension REF: p. 82 OBJ: 3
TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
7. The nurse writes two patient problems: (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?
a. The second diagnosis needs no defined nursing interventions.
b. The second diagnosis needs medical intervention.
c. The second diagnosis will not need to be evaluated.
d. The second diagnosis reflects a problem that does not yet exist.
ANS: D
The actual patient problem represents a condition that is currently present. “Risk for”
diagnoses are those that the patient is susceptible to, but not yet troubled by.
DIF: Cognitive Level: Comprehension REF: p. 84 OBJ: 4
TOP: Patient problem KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
8. What framework does the establishment of priorities of care during the planning phase of the
nursing process often use?
