Chapter 05: Nursing Process:
Foundation for Clinical Judgment
1. The nurse writes the following o n the patients chart: The patient will have
complete healing of the surgical incision on the right lower quadrant of
the abdomen in 3 weeks. This is a(n)
a. Nursing diagnosis
b. Assessment
c. Evaluation
d. Outcome identification
CORRECT ANSWER: D
Feedback:
According to the ANAs Nursing: Scope and Standards of Practice ,
outcome identification refers to formulating and documenting
measurable, realistic, patient - focused goals.
2. Which organization defines the nursing diagnosis?
a. American Nurses Association
b. North American Nursing Diagnosis Association International
c. American Association of Colleges of Nursing
d. Sigma Theta Tau International
CORRECT ANSWER: B
Feedback:
, The North American Nursing Diagnosis Association International
defines the nursing diagnosis a s a clinical judgment about individual,
famil y, or community responses to actual or potential health
problems/life processes.
3. Which of the following healthcare professionals are licensed to make a
nursing diagnosis?
a. Licensed practical nurses
b. Registered nurses
c. Social workers
d. Physicians assistants
CORRECT ANSWER: B
Feedback:
Registered nurses are educated and licensed to make nursing diagnoses.
4. A patient has had an appendectom y. He has an incision at the right lower
quadrant of the abdomen. Nurse has written: Alteration in skin integrit y
related to incision at right lower quadrant of the abdomen. This is
a. A planned outcome
b. Subjective data
c. A nursing intervention
d. An actual nursing diagnosis
CORRECT ANSWER: D
, Feedback:
Diagnosing human responses to actual or potential health problems is
the second phase of the nursing process.
5. An in-depth history and physical builds the
a. Plan of care
b. Future interventions
c. Database
d. Secondary source
CORRECT ANSWE R: C
Feedback:
An in-depth history and physical assessment are usuall y required at
admission to a hospital or long -term care facilit y, or during the first
visit by communit y or home health nurse.
6. The nurse caring for a newl y admitted patie nt recognizes that the patients
past chart at an acute care facilit y is considered to be the
a. Primary source
b. Secondary source
c. Subjective data
d. Nursing diagnosis
CORRECT ANSWER: B
Feedback:
Secondary sources include famil y m embers, significant others, other
healthcare professionals, health records, and literature review.
Foundation for Clinical Judgment
1. The nurse writes the following o n the patients chart: The patient will have
complete healing of the surgical incision on the right lower quadrant of
the abdomen in 3 weeks. This is a(n)
a. Nursing diagnosis
b. Assessment
c. Evaluation
d. Outcome identification
CORRECT ANSWER: D
Feedback:
According to the ANAs Nursing: Scope and Standards of Practice ,
outcome identification refers to formulating and documenting
measurable, realistic, patient - focused goals.
2. Which organization defines the nursing diagnosis?
a. American Nurses Association
b. North American Nursing Diagnosis Association International
c. American Association of Colleges of Nursing
d. Sigma Theta Tau International
CORRECT ANSWER: B
Feedback:
, The North American Nursing Diagnosis Association International
defines the nursing diagnosis a s a clinical judgment about individual,
famil y, or community responses to actual or potential health
problems/life processes.
3. Which of the following healthcare professionals are licensed to make a
nursing diagnosis?
a. Licensed practical nurses
b. Registered nurses
c. Social workers
d. Physicians assistants
CORRECT ANSWER: B
Feedback:
Registered nurses are educated and licensed to make nursing diagnoses.
4. A patient has had an appendectom y. He has an incision at the right lower
quadrant of the abdomen. Nurse has written: Alteration in skin integrit y
related to incision at right lower quadrant of the abdomen. This is
a. A planned outcome
b. Subjective data
c. A nursing intervention
d. An actual nursing diagnosis
CORRECT ANSWER: D
, Feedback:
Diagnosing human responses to actual or potential health problems is
the second phase of the nursing process.
5. An in-depth history and physical builds the
a. Plan of care
b. Future interventions
c. Database
d. Secondary source
CORRECT ANSWE R: C
Feedback:
An in-depth history and physical assessment are usuall y required at
admission to a hospital or long -term care facilit y, or during the first
visit by communit y or home health nurse.
6. The nurse caring for a newl y admitted patie nt recognizes that the patients
past chart at an acute care facilit y is considered to be the
a. Primary source
b. Secondary source
c. Subjective data
d. Nursing diagnosis
CORRECT ANSWER: B
Feedback:
Secondary sources include famil y m embers, significant others, other
healthcare professionals, health records, and literature review.
