The Nursing Process Quiz I. Choose the best answer from the letter choices succeeding each numbered item. Ms. Cabacungan complains of pain in her chest, difficulty of breathing and cough. The nurse would be correct if she documents these data as : Objective data Observable data c. Subjective data d. General information Which of the following assessment findings would be documented as objective data? Leg pain and calf tenderness c. Dizziness and headache in PM Redness and swelling on arm d. Weakness and nausea A nurse is performing a physical assessment, which of the following would indicate a problem? Clear bilateral lung sounds Jaundice 4. Apical heart rate – 112 bpm 5. Afebrile Erythema of lower extremities 6. Cyanosis on fingers 7. Respiratory rate – 19 breaths/min 1,3,4 and 5 c. 3,4,5,2 and 1 2,3,4 and 6 d. 3,2,4,6 and 1 4. The nurse is organizing the assessment data elicited from her patient and groups related information together. The nurse is doing what phase of the Nursing process? a. Evaluation c. Outcome identification b. Assessment d. Implementation 5. Which of the following is not an activity of the nurse during evaluation? a. Measuring goal attainment b. Revising the care plan c. Collection of data d. Performing Nursing orders 6. Which of the following is Incorrect regarding the establishment of priorities in patient? a. Airway should always be given Highest priority b. Clients with unstable condition should be given priority over those who are stable c. Attend to equipment and apparatus like IV fluids, IFCs and drainage tubes first d. Actual problems take precedence over potential problems 7. Bella Flores has just undergone surgery on her right lower leg. During the night, she required an analgesic to help her sleep. She doesn’t have appetite to eat but is able to take in liquids without nausea. Which of the following nursing diagnosis should be given highest priority? a. Impaired tissue perfusion: peripheral b. Imbalanced nutrition: Less than body requirement c. Pain d. Impaired physical mobility 8. A patient is being positioned by the nurse because of complaints of difficulty of breathing. The action of the nurse indicates what phase of the nursing process? a. Implementation c. Assessment b. Evaluation d. Outcome Identification 9. The first component of a nursing diagnosis statement consists of : a. Etiology c. Problem b. Signs and symptoms d. Related factors 10. In the Nursing diagnosis “Impaired physical mobility related to joint stiffness as evidenced by limited range of motion and difficulty turning”, the etiology of the problem is: a. Limited range of motion c. physical mobility b. Joint stiffness d. Difficulty turning 11. Which of the following is included in a client’s plan of care? a. Doctor’s orders, demographic data, medication administration and rationales b. Client’s assessment data, medical treatments with rationales, diagnostic results and significance c. Collected documentation of all team members providing care for the client d. Client’s nursing diagnosis, goals, expected outcomes and nursing interventions 12. When establishing priorities for a client’s plan of care, the nurse should rank which of the following as the lowest priority? a. Client’s needs regarding referrals b. Safety-related needs c. Needs of family members involved in the plan of care d. Client’s social, love and belongingness needs 13. Which of the following are the essential components for outcome identification? a. Target date, nursing action, measurement criteria and desired client behavior b. Client behavior, measurement criteria, conditions under which the behavior occurs and target date c. Client behavior, target date and conditions under which the behavior occurs d. Target date, nursing action, measurement criteria and desired client behavior 14. As an intervention for controlling pain of a postoperative client, a nurse administers analgesic. This activity of the nurse is an example of a/an: a. independent nursing action c. collaborative nursing action b. dependent nursing action d. legal nursing action 15. As a nurse taking the next shift, which of the following patient conditions should the you prioritize? a. A 29 y/o post operative patient complaining of thirst b. A 17 y/o patient with left arm fracture secondary to mauling complaining of severe QApain c. A 58 y/o post stroke victim with left-sided paralysis with bluish discoloration of nails d. A neonate with respiratory rate of 32 breaths per minute 16. Which of the following nursing diagnoses should be dealt with immediately? a. High risk for infection c. Impaired physical mobility b. Anxiety/ fear d. High risk for fluid volume deficit 17. On assessment, the nurse obtains the following findings : BP-130/90 mmHg; PR- o 108bpm; RR-20; T- 37.4 C; with complaints DOB, headache, diziness and expressed worries about her 17 y/o son left at home. Which of the possible problems would be of least priority? a. BP- 130/90 b. Worries on her son c. Difficulty of breathing d. headache and dizziness 18. Using the P-E-R-S-O-N-S format in data clustering, where would you include the assessment finding “non-pitting edema at Right forearm site of previous IV”? a. Elimination c. Safety and security b. Nutrition d. Oxygenation 19. Which of the following patients should be prioritized according to Maslow’s Theory? a. Angelina, a post appendectomy patient who is complaining of pain b. Yaya, such a loser, with Alzheimer’s who will be institutionalized c. Ogie, a diabetic patient who awaits instructions for self-injection d. Bitoy, a newly admitted patient, anxious about his scheduled endoscopy 20. In the diagnostic statement “Fluid volume excess r/t decreased venous return as manifested by edema on lower extremity”, the etiology of the problem is: a. Edema b. Decreased venous return c. Excess fluid volume d. Impaired circulation 21. Nursing diagnoses must meet specific criteria to reflect both the client's problem and the possible etiology involved. Which of the following is an appropriately written nursing diagnosis? a. Pain related to insufficient use of medication b. Pain related to difficulty ambulating c. Anxiety related to cardiac monitor d. Bedpan required frequently as a result of altered elimination pattern 22. After visiting with the client the nurse documents the assessment data. Both objective and subjective information has been obtained during the assessment. Which of the following is classified as subjective data? a. Client appears sleepy b. No distress noted c. Abdomen soft and non-tender d. States feels anxious and tense 23. Nursing interventions should be documented according to specific criteria so they are clearly understood by other members of the nursing team. The intervention statement “Nurse will apply warm, wet soaks to the client's leg while the client is awake” lacks which of the following components? a. Method b. Quantity c. Frequency d. Qualifications of the person who will perform the task 24. Nursing diagnoses meet specific criteria so they accurately reflect both the client's problem and the possible etiology involved. Of the following statements, which one is an example of an appropriately written nursing diagnosis? a. Acute pain related to left mastectomy b. Impaired gas exchange related to altered blood gases c. Deficient knowledge related to need for cardiac catherization d. Need for high protein diet related to alteration in nutrition 25. The nurse notes a narcotic is to be administered per epidural cath. The nurse, however, does not know how to perform this procedure. Which aspects of the implementation process should be followed? a. Seek assistance b. Reassess the client c. Use interpersonal skills d. Critical decision making II. Identify whether the following are Subjective or Objective 1. Skin with blemishes 2. Dizziness 3. PR-110bpm 4. Complaints of boredom 5. Feels rested upon awakening 6. Muscle tone 7. Last menstrual period 8. Cyanosis 9. Foul smelling breath 10. Tingling sensation and numbness 11. Dirty finger nails 12. Temp-38.1oC 13. Stomachache 14. Profuse sweating(diaphoresis) 15. Rashes data.