drdr drdr drdr drdr drdr drdr
8TH EDITION BY EASTON
drdr drdr drdr drdr
,CH 1: An Introduction to Evidence-Based Clinical Practice Guidelines
dr dr dr dr drdr drdr drdr drdr dr dr dr dr
MULTIPLE CHOICE d rdr
• What is the primary purpose of the nursing assessment?
drdr drdr d rd r dr dr drdr drdr drd r d r d r
• Identifying underlying pathologic conditions drdr d r d r d r d r
• Assisting the physician in identifying medical conditions drdr drdr drdr drdr drdr d r d r
• Determining the patients mental status drdr drdr dr dr d rd r
• Exploring patient responses to health problems drdr drdr drdr d rd r d r d r
PRECISE ANSWER:-D drdr
REASONING:->>> A nursing assessment is done to identify the drdr drdr d rd r drdr d rdr d rd r drdr drdr
patients response to health problems. During the nursing assessment
d rdr drdr drdr drdr drdr dr dr drdr d rd r drdr
phase, a comprehensive information base is developed through a
drdr drd r drdr drdr drdr drdr d rd r d rdr drdr
physical examination, nursing history, medication history, and
drdr drdr drdr drdr dr dr d rdr drdr
professional observation. Identifying underlying pathologic conditions
drdr drdr d rd r drdr drdr d rdr
and assisting thephysician in identifyingmedical conditions is not
drdr drdr drdr r
d dr dr drdr drdr drd r drdr
part of the nursing process. Determining the patients mental status is
d rdr drdr drdr drdr drdr drdr dr dr drdr drdr drdr d rd r
one part of the nursing assessment, but it is not the primary
drdr drdr drdr d rdr drdr drdr drdr drdr drdr drdr drdr drdr
purpose.
drdr
DIFFICULT: Cognitive Level: drdr d rd r
ComprehensionREF: dm 36 OBJ: 1
drdr r
d drd r d rd r drd r drdr
| 3 TOPIC: Nursing Process Step:
drdr drdr drdr d rd r drdr drdr
Assessment
drdr
MSC: NCLEX Patient Needs Category: Health Promotion and Maintenance
drdr d rdr drdr drdr drdr drdr d rd r drdr
• What is the basis of the NANDA I taxonomy? drdr drdr drdr drdr drdr d r dr drdr drd r
• Functional health patterns drdr drdr
• Human response patterns drdr drdr
• Basic human needs drdr drdr
• Pathophysiologic
drdr needsPRECISE ANSWER:-B dr drdr
REASONING:->>> The NANDA I taxonomy d r d r d r d r d r d r d r d r d r d r identifies drdr drdr d r d r human
response patterns. Functional components of health patterns are
d r d r d r d r drdr drdr drdr drdr drdr
limited to activity, fluid volume, nutrition, self
drdr drdr care, and sensory
drdr drdr drdr drdr drdr d r d r drdr drdr
perception. Basic human needs comprise less than merely health
drdr drdr drdr drdr drdr drdr drdr drdr drdr
patterns. Pathophysiologic
drdr needs arenot part of the scope of
drdr d r d r d r d r drdr drdr drdr drd r drdr
NANDAI.
drdr dr
,DIFFICULT: Cognitive Level: drdr d rdr
KnowledgeREF: pp. 37-38
drdr r
d d rdr drdr
OBJ: 5 TOPIC:
drdr drdr drdr
Nursing Process Step: Diagnosis d r dr d rd r drdr
MSC: NCLEX Patient Needs Category: Physiological Integrity
drd r drdr drdr drdr drdr drdr
• Which task is included in the assessment step of the nursing process?
drdr d rdr drdr drdr drdr drd r drdr drdr drdr d rdr d r d r
• Establishing patient goals/outcomes drdr d r d r
• Implementing the nursing care plan (NCP) drdr drdr drdr drdr d r d r
• Measuring goal/outcome achievement drdr d r d r
• Collecting and communicating data drdr drdr d r d r
PRECISE ANSWER:-D drdr
REASONING:->>> Data are collected and communicated in drdr drdr drdr drdr drdr drdr
the assessment phase of thenursing process. Establishing goals
drdr drdr drdr drdr drdr drdr drdr drdr
is the function of planning.
drdr drdr drdr d rd r d rdr
Implementing the NCP is the function of implementation. drdr drdr drdr drdr drdr drdr drdr
Measuring outcome achievement is the function of evaluation.
drdr drdr drdr d rd r drdr drdr d rd r drdr
DIFFICULT: Cognitive Level: drdr d rd r
ComprehensionREF: dm 36 OBJ: 2
drdr r
d drdr dr dr d rdr d rdr
| 3 TOPIC: Nursing Process Step:
drdr drdr drdr d rd r drdr drdr
Assessment
drdr
MSC: NCLEX Patient Needs Category: Health Promotion and Maintenance
drdr d rdr drdr drdr drdr drdr d rd r drdr
• Which statement regarding nursing diagnoses is accurate?
d rdr drdr drdr drdr drdr d r d r
• Nursing diagnoses remain the same for as long as the disease is present.
drdr drd r d rdr drdr drdr drdr d rd r drdr d rdr drdr d rdr d r d r
• Nursing diagnoses are written to identify disease states. d rdr d rd r drdr drdr drdr drdr d r dr
• Nursing diagnoses describe patient problems that professional nurses treat.
drdr drdr drdr drdr d rd r drdr drdr d r d r
• Nursing diagnoses identify causes related to illness. d rdr drdr drd r drdr drdr drdr
PRECISE ANSWER:-C drdr
REASONING:->>> Diagnostic statements identify problems a drdr drdr drdr drdr drdr
professional nurse is independently able totreat within the scope of
drdr drdr drdr d rd r d rdr drdr d rd r d rdr d rd r d rdr
professional practice. Nursing diagnoses vary with the changing
drdr drd r drdr drdr drdr drdr drdr drdr
conditionof the patient. The response patterns are unique to the
drdr dr drdr dr dr dr dr d rd r d r dr drdr drdr drd r drdr
patient and are not disease specific. Nursing diagnoses describe the
d rdr drd r drdr drd r drdr drd r dr dr drdr drdr drdr
patients human response pattern.
drdr drdr drdr drdr
DIFFICULT: Cognitive Level: Comprehension drdr d rd r drdr
, REF: pp. 37-38 OBJ: 5 TOPIC: Nursing
drd r d rdr drdr drdr drdr dr dr
Process Step: Diagnosis drdr drd r
MSC: NCLEX Patient Needs Category: Physiological Integrity
drd r drdr drdr drdr drdr drdr
• What do the classification systems NIC and NOC provide?
drdr d rd r drdr drd r drdr drd r d rdr drdr
• Individualized data banks of treatments related to disease processes drdr drdr d rdr drdr drdr drdr drdr dr dr
• Standardized language for reporting and analyzing nursing care d rd r drdr drdr d rd r d rd r drdr d rdr d r d r delivery
• A measure for cost containment within medical institutions
drdr drdr drdr drdr drdr drdr d r d r
• Specialized interventions for rare diseases drdr drd r drdr d r d r
PRECISE ANSWER:-B drdr
REASONING:->>> Nursing classification systems such as NIC and drdr drdr drdr d rd r drdr drdr d rd r
NOCare designed to provide a standardized language for reporting
d rd r dr d rd r dr dr drdr d rd r drd r drdr drdr drdr
and analyzing nursing care delivery that is individualized for each
drdr drdr d rdr d rd r drdr drdr drdr d rd r drdr drdr
patient.
drdr
Standardized terminology assists practitioners in the implementation of d rd r drdr drdr drdr d rd r d rdr drdr
thefive phases of the nursingprocess. Classification systems are not
d rdr dr drdr drdr drdr drdr drd r drdr drdr d rdr
related to disease process and are not used for financial purposes.
drd r dr dr drdr d rdr drdr drdr drdr drdr drdr drdr drdr
Classification systems include interventions for all health conditions.
drdr drdr drdr drdr drdr drdr drdr drdr
DIFFICULT: Cognitive Level: dr dr drdr
Knowledge REF: dm 34 OBJ: 11
drd r drdr dr dr d r dr drdr d rd r
TOPIC: NursingProcess Step:
drdr d rd r r
d drdr
Implementation
d rd r
MSC: NCLEX Patient Needs Category: Safe, Effective Care Environment
drd r drdr drdr drdr d rd r drdr drdr drdr
• Which type of nursing diagnosis will be written when the
drdr drdr drdr drdr drdr drdr drdr drdr d rdr
patientexhibits factors that makes him or her susceptible
drdr r
d drdr drdr drdr drdr drdr d rdr d rdr
to the development of a problem?
drd r drdr drdr drdr drdr drdr
• Actual diagnosis drdr
• Risk diagnosis drdr
• Possible diagnosis drdr
• Wellness diagnosis d rd r
PRECISE ANSWER:-B drdr
REASONING:->>> When patients have the potential or risk for a drdr d rdr drdr drdr dr dr drd r d rd r d rd r drdr
problemto develop, a risk diagnosis is written. These diagnoses are
d rdr dr drd r drdr drd r drdr drdr drdr drdr drdr drdr
two part statements such as Riskfor falls related to unsteady gait. An
drd r drdr drdr drdr drd r d rd r d rdr drdr d rdr drdr drdr drdr
actual diagnosis consists of a NANDA diagnostic label, contributing
drdr drdr drdr drdr drdr drdr drdr drdr drd r
factor (if known), and defining characteristics such as signs and
d rdr drd r drdr d r dr drdr drdr drdr d rdr drdr drdr
symptoms. A possible nursing diagnosis
drdr drdr drdr drdr drdr