7745_Ch04_183-296 03/12/18 9:35 AM Page 183
4
Essential Components
of Nursing Care
Nursing Process
KEYWORDS
Copyright © 2019. F. A. Davis Company. All rights reserved.
The following words include nursing/medical terminology, concepts, principles, and information
relevant to content specifically addressed in the chapter or associated with topics presented in it.
English dictionaries, nursing textbooks, and medical dictionaries, such as Taber’s Cyclopedic
Medical Dictionary, are resources that can be used to expand your knowledge and understanding
of these words and related information.
Care plan, types:
Case management
Clinical pathway
Computerized
Individualized
Standardized
Clinical record, parts of:
Admission sheet
Consents
Flow sheets
Health-care provider’s prescriptions
History and physical
Laboratory/diagnostic test results
Medication administration
record
Progress notes
Data, sources of:
Primary
Secondary
Data, types:
Objective
Subjective
Data collection methods:
Auscultation
Examination
Inspection
Interview
Observation
Palpation
Percussion
Functions of the nurse:
Dependent
Independent
Interdependent
Goal, components of:
Achievable
Measurable
Realistic
Time frame
Inference
Intervention skills:
Assisting
Collaborating
Coordinating
Managing
Monitoring
Protecting
Supporting
Sustaining
Teaching
Nursing diagnosis:
Diagnostic label
Related to factors: contributing factors,
etiology
As evidenced by: signs and symptoms,
defining characteristics
Nursing process:
Assessment
Analysis
Planning
Implementation
Evaluation
Outcomes:
Actual
Expected
Reasoning:
Deductive
Inductive
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
183
7745_Ch04_183-296 03/12/18 9:35 AM Page 184
184
FUNDAMENTALS SUCCESS
NURSING PROCESS: QUESTIONS
1. A nurse makes a home-care visit for a client who had total hip replacement surgery
1 week ago. During which of the five steps in the nursing process does the nurse
determine whether outcomes of care are achieved?
1. Implementation
2. Evaluation
3. Planning
4. Analysis
2. When considering the nursing process, the word “observe” is to “assess” as the word
“explore” is to which of the following words?
1. Plan
2. Analyze
3. Evaluate
4. Implement
3. Which statement is related to the concept that is central to the nursing process?
1. It is dynamic rather than static.
2. It focuses on the role of the nurse.
3. It moves from the simple to the complex.
4. It is based on the client’s medical problem.
4. Which word best describes the role of the nurse when using the nursing process to
meet the needs of the client holistically?
1. Teacher
2. Advocate
3. Surrogate
4. Counselor
Copyright © 2019. F. A. Davis Company. All rights reserved.
5. Which word is most closely associated with scientific principles?
1. Data
2. Problem
3. Rationale
4. Evaluation
6. A pebble dropped into a pond causes ripples on the surface of the water. Which part
of the nursing diagnosis is directly related to this concept?
1. Defining characteristics
2. Outcome criteria
3. Etiology
4. Goal
7. A nurse teaches a client to use visualization to cope with chronic pain. Which step of
the nursing process is associated with this nursing intervention?
1. Planning
2. Analysis
3. Evaluation
4. Implementation
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
7745_Ch04_183-296 03/12/18 9:35 AM Page 185
CHAPTER 4 ESSENTIAL COMPONENTS
OF
NURSING CARE
8. A nurse is caring for several clients. Which nursing action reflects the assessment
step of the nursing process?
1. Taking a client’s apical pulse rate every 2 hours after the client is admitted for an
episode of chest pain
2. Scheduling a client’s fluid intake over 12 hours when the client has a fluid
restriction
3. Examining a client for injury after a fall in the bathroom
4. Obtaining a client’s respiratory rate after a nebulizer treatment
9. A nurse is caring for a client with a fever. Which is a well-designed goal for this
client?
1. “The client will have a lower temperature.”
2. “The client will be taught how to take an accurate temperature.”
3. “The client will maintain fluid intake adequate to prevent dehydration.”
4. “The client will be given aspirin every eight hours whenever necessary.”
10. Which should the nurse do during the evaluation step of the nursing process?
1. Set the time frames for goals.
2. Revise a plan of care.
3. Determine priorities.
4. Establish outcomes.
11. A client is admitted to a postoperative surgical unit after abdominal surgery. During
which step of the nursing process does the nurse determine which actions are
required to meet the needs of this client?
1. Implementation
2. Assessment
3. Planning
4. Analysis
12. Which information supports the appropriateness of a nursing diagnosis?
1. Defining characteristics
2. Planned interventions
3. Diagnostic statement
4. Related risk factors
Copyright © 2019. F. A. Davis Company. All rights reserved.
13. Which is the primary goal of the assessment phase of the nursing process?
1. Build trust
2. Collect data
3. Establish goals
4. Validate the medical diagnosis
14. Which most directly influences the planning step of the nursing process?
1. Related factors
2. Diagnostic label
3. Secondary factors
4. Medical diagnosis
15. A nurse collects information about a client. Which should the nurse do next?
1. Plan nursing interventions.
2. Write client-centered goals.
3. Formulate nursing diagnoses.
4. Determine significance of the data.
16. When two nursing diagnoses appear closely related, which should the nurse do first
to determine which diagnosis most accurately reflects the needs of the client?
1. Reassess the client.
2. Examine the related to factors.
3. Analyze the secondary to factors.
4. Review the defining characteristics.
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
185
7745_Ch04_183-296 03/12/18 9:35 AM Page 186
186
FUNDAMENTALS SUCCESS
17. Which is the primary reason why a nurse performs a physical assessment of a newly
admitted client?
1. Identify if the client is at risk for falls.
2. Ensure that the client’s skin is totally intact.
3. Identify important information about the client.
4. Establish a therapeutic relationship with the client.
18. A nurse evaluates a client’s response to a nebulizer treatment. To which aspect of the
nursing process is this evaluation most directly related?
1. Goal
2. Problem
3. Etiology
4. Implementation
19. A nurse concludes that a client’s elevated temperature, pulse, and respirations are
significant. Which step of the nursing process is being used when the nurse comes to
this conclusion?
1. Implementation
2. Assessment
3. Evaluation
4. Analysis
20. When the nurse considers the nursing process, the word “identify” is to “recognize”
as the word “do” is to which of the following words?
1. Implement
2. Evaluate
3. Analyze
4. Plan
Copyright © 2019. F. A. Davis Company. All rights reserved.
21. A nurse is collecting subjective data associated with a client’s anxiety. Which
assessment method should be used to collect this information?
1. Observing
2. Inspection
3. Auscultation
4. Interviewing
22. A nurse assesses that a client has slurred speech and a retained bolus of food in the
mouth. Which additional condition assessed by the nurse should be clustered with
these clinical indicators? Select all that apply.
1. _____ Hoarseness
2. _____ Dyspepsia
3. _____ Coughing
4. _____ Drooling
5. _____ Gurgling
6. _____ Plaque
23. Nurses use the nursing process to provide nursing care. These statements reflect
nursing care being provided to several clients. Place the statements in order as the
nurse progresses through the steps of the nursing process, starting with assessment
and ending with evaluation.
1. “Did you sleep last night after I gave you the sleeping medication?”
2. “The client’s clinical manifestations indicate dehydration.”
3. “The client will have a bowel movement in the morning.”
4. “What brought you to the hospital today?”
5. “I am going to give you an enema.”
Answer: _______________________
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
7745_Ch04_183-296 03/12/18 9:35 AM Page 187
CHAPTER 4 ESSENTIAL COMPONENTS
OF
NURSING CARE
24. A nurse is caring for a client with a urinary elimination problem. Which is an
accurately stated goal? Select all that apply.
1. _____ “The client will be taught how to use a bedpan while on bedrest.”
2. _____ “The client will experience fewer incontinence episodes at night.”
3. _____ “The client will transfer from a chair to the toilet independently and
safely.”
4. _____ “The client will be assisted to the commode every 2 hours and whenever
necessary.”
5. _____ “The client will experience one or no events of urinary incontinence daily
within 6 weeks.”
25. Which human response identified by the nurse is an example of objective data?
Select all that apply.
1. _____ Irregular radial pulse of 50 beats per minute
2. _____ Wheezing on expiration
3. _____ Temperature of 99°F
4. _____ Bradypnea
5. _____ Vomiting
26. Place the following statements that reflect the analysis step of the nursing process in
the order in which they should be implemented.
1. Cluster data.
2. Identify conclusions.
3. Interpret clustered data.
4. Communicate conclusion to other health team members.
5. Identify when additional data are needed to further validate clustered data.
Answer: _______________________
Copyright © 2019. F. A. Davis Company. All rights reserved.
27. Which client statement provides subjective data? Select all that apply.
1. _____ “I’m not sure that I am going to be able to manage at home by myself.”
2. _____ “I can call a home-care agency if I feel I need help at home.”
3. _____ “What should I do if I have uncontrollable pain at home?”
4. _____ “Will a home health aide help me with my care at home?”
5. _____ “I’m afraid because I live alone and I’m on my own.”
28. Which nursing action reflects an activity associated with the analysis step of the
nursing process? Select all that apply.
1. _____ Formulating a plan of care
2. _____ Identifying the client’s potential risks
3. _____ Grouping data into meaningful relationships
4. _____ Designing ways to minimize a client’s stressors
5. _____ Making decisions about the effectiveness of client care
29. A nurse is interviewing a client. Which client statement is an example of objective
data? Select all that apply.
1. _____ “I am hungry.”
2. _____ “I feel very warm.”
3. _____ “I ate half my lunch.”
4. _____ “I have a rash on my arm.”
5. _____ “I have the urge to urinate.”
6. _____ “I vomit every time I eat something.”
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
187
7745_Ch04_183-296 03/12/18 9:35 AM Page 188
188
FUNDAMENTALS SUCCESS
30. Which statement indicates that the nurse is using inductive reasoning? Select all
that apply.
1. _____ A client is admitted with a diagnosis of dehydration, and the nurse assesses
the client’s skin for tenting.
2. _____ A nurse observes a client fall out of bed on the right hip and immediately
assesses the client for right hip pain.
3. _____ A client has an elevated white blood cell count and a fever. The nurse
concludes that the client may have an infection.
4. _____ A client who is scheduled for surgery is crying, trembling, and has a rapid
pulse. The nurse makes the inference that the client is anxious.
5. _____ A nurse receives a call from the admission department that a client with
hypoglycemia is being admitted to the unit. The nurse plans to assess the
client for pale, cool, clammy skin and a low blood glucose level.
31. The following statements reflect steps in the nursing process. Place the statements in
order as the nurse advances through the steps of the nursing process, beginning with
assessment and ending with evaluation.
1. “The client is encouraged to attempt to defecate after meals.”
2. “The client reports not having had a bowel movement for 8 days.”
3. “The client has constipation related to immobility and inadequate fluid intake.”
4. “The client will have a bowel movement within 2 days that is of soft consistency.”
5. “The client’s stool is still hard and dry 2 days after initiating an increase in fluids
and activity.”
Answer: _______________________
Copyright © 2019. F. A. Davis Company. All rights reserved.
32. A nurse is interviewing a client at the change of shift. Which client statement reflects
subjective data? Select all that apply.
1. _____ “When I lift my head up off the bed, I feel like vomiting.”
2. _____ “I just used the urinal, and it needs to be emptied.”
3. _____ “My pain feels like a 5 on a scale of 0 to 5.”
4. _____ “The physician said I can go home today.”
5. _____ “I gained 10 pounds in the last month.”
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
7745_Ch04_183-296 03/12/18 9:35 AM Page 189
CHAPTER 4 ESSENTIAL COMPONENTS
OF
NURSING CARE
33. A nurse identifies that the client’s report of decreased activity and intake of fluids
may be the underlying cause of the client’s constipation. Place an X over the word
that reflects the step of the nursing process that is functioning.
Copyright © 2019. F. A. Davis Company. All rights reserved.
SIS
ALY
AN
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
189
7745_Ch04_183-296 03/12/18 9:35 AM Page 190
190
FUNDAMENTALS SUCCESS
34. A client is transferred from the emergency department to a medical-surgical unit at
6:30 p.m. The nurse arriving on duty at 8 p.m. reviews the client’s clinical record.
Which information documented in the clinical record reflects the evaluation step of
the nursing process?
1. Productive cough
2. No dizziness reported by the client
3. Seek prescription for chest physiotherapy
4. Acetaminophen 650 mg administered at 5 p.m.
CLIENT’S CLINICAL RECORD
Nurse’s Transfer Note From the Emergency Department
Client admitted to the emergency department at 3 p.m. stating experiencing shor tness of
breath that became worse over the last few days. Sputum culture obtained and metabolic
panel and complete blood count drawn. Oxygen prescribed at 2 L via nasal cannula, acetaminophen 650 mg PO administered at 5 p.m. Client transferred to 5 South with a diagnosis of rule out pneumonia at 6 p.m.
Vital Signs
Oxygen saturation: 85%
Temperature: 102.4°F, temporal
Pulse: 92 beats per minute, regular rate
Respirations: 28 breaths per minute
Blood pressure: 160/90 mm Hg
Copyright © 2019. F. A. Davis Company. All rights reserved.
Progress Note
7 p.m.: IV 0.45% sodium chloride running at 100 mL per hour. IV site is clean, dry, and intact. Client has a productive cough and excessive respirator y secretions, and respirations
are 28 breaths per minute. Called primary health-care provider for a prescription for chest
physiotherap y. Client states feeling tired and nauseated. Client had 4 ounces of soup and
3 ounces of water and refused rest of dinner. Client assisted to the bathroom to void; no
dizziness reported by the client.
35. The nurse assesses a client and collects a variety of data. Identify the human response
that is subjective data. Select all that apply.
1. _____ Nausea
2. _____ Jaundice
3. _____ Ecchymosis
4. _____ Diaphoresis
5. _____ Hypotension
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
7745_Ch04_183-296 03/12/18 9:35 AM Page 191
Copyright © 2019. F. A. Davis Company. All rights reserved.
NURSING PROCESS: ANSWERS AND RATIONALES
1. 1. During the implementation step of the nursing process, outcomes are not determined;
instead, planned nursing care is delivered.
2. Evaluation occurs when actual outcomes
are compared with expected outcomes
that reflect goal achievement. If the goal
is achieved, the client’s needs are met.
3. During the planning step of the nursing
process, expected outcomes are determined,
but their achievement is measured in another step of the nursing process.
4. During the analysis step of the nursing
process, outcomes are not determined; instead, the nurse identifies human responses
to actual or potential health problems.
2. The nursing process focuses on the needs of
the client, not the role of the nurse.
3. Moving from the simple to the complex
is a principle of teaching, not the nursing
process. The nursing process is a complex,
interactive, five-step problem-solving
process designed to meet a client’s needs. It
requires an understanding of systems and
information-processing theory and the
critical-thinking, problem-solving, decisionmaking, and diagnostic-reasoning processes.
4. The nursing process is concerned with a
person’s human responses to actual or
potential health problems, not the client’s
medical problem.
2. 1. The definitions of the words “observe” and
“assess” are similar. Observe means to view
something scientifically, and assess means to
collect information. The word “plan” does
not fit the analogy because the definitions
of the words “plan” and “explore” are not
similar. Explore means to examine. Plan
means to design an intention.
2. The definitions of the words “observe”
and “assess” are similar. Observe means
to view something scientifically, and assess means to collect information. The
word “analyze” fits the analogy. Explore
means to examine. Analyze means to
investigate.
3. The definitions of the words “observe” and
“assess” are similar. Observe means to view
something scientifically, and assess means to
collect information. The word “evaluation”
does not fit the analogy because the definitions of explore and evaluate are not similar.
Explore means to examine. Evaluation
within the concept of the nursing process
means to come to a conclusion about a
client’s response to a nursing intervention.
4. The definitions of the words “observe” and
“assess” are similar. Observe means to examine something scientifically, and assess means
to collect information. The word “implement” does not fit the analogy because the
definitions of explore and implement are not
similar. Explore means to examine. Implement means to carry out an action.
4. 1. Although functioning as a teacher is an
important role of the nurse, it is a limited
role compared with another option. As a
teacher, the nurse helps the client gain new
knowledge about health and health care to
maintain or restore health.
2. When the nurse supports, protects, and
defends a client from a holistic perspective, the nurse functions as an advocate.
Advocacy includes exploring, informing,
mediating, and affirming in all areas to
help a client navigate the health-care
system, maintain autonomy, and achieve
the best possible health outcomes.
3. The word surrogate is not the word that
best describes the role of the nurse providing holistic care. The nurse is placed in the
surrogate role when a client projects onto
the nurse the image of another and then responds to the nurse with the feelings for the
other person’s image.
4. Although functioning as a counselor is an
important role of the nurse, it is a limited
role compared with another option. As counselor, the nurse helps the client improve interpersonal relationships, recognize and deal
with stressful psychosocial problems, and
promote achievement of self-actualization.
3. 1. The nursing process is a dynamic
five-step problem-solving process
(assessment, analysis, planning, implementation, and evaluation) designed to
diagnose and treat human responses to
health problems.
5. 1. The word “data” (information) is not associated with the term “scientific principles”
(established rules of action).
2. The word “problem” (difficulty) is not associated with the term “scientific principles”
(established rules of action).
3. The word “rationale” (justification
based on reasoning) is closely associated
with the term “scientific principles”
(established rules of action). Scientific
principles are based on rationales.
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
191
7745_Ch04_183-296 03/12/18 9:35 AM Page 192
192
FUNDAMENTALS SUCCESS
4. The word “evaluation” (determining the
value or worth of something) is not associated with the term “scientific principles”
(established rules of action).
Copyright © 2019. F. A. Davis Company. All rights reserved.
6. 1. Defining characteristics do not contribute
to the problem statement, but they support
or indicate the presence of the nursing diagnosis. Defining characteristics are the
major and minor signs and symptoms that
support the presence of a nursing diagnosis.
2. Outcome criteria are not a part of the nursing diagnosis. Outcome criteria (goals) are
part of the planning step of the nursing
process.
3. The etiology (also known as related to or
contributing factors) includes the conditions, situations, or circumstances that
cause the development of the human
response identified in the problem statement of the nursing diagnosis. The etiology precipitates the human response,
just as a pebble dropped in a pond causes
ripples on the surface of water.
4. Goals are not part of the nursing diagnosis.
Goals are the expected outcomes or what is
anticipated that the client will achieve in
response to nursing intervention.
7. 1. This is not an example of the planning step
of the nursing process. During the planning
step, the nurse identifies the nursing interventions that are most likely to be effective.
2. This is not an example of the analysis step
of the nursing process. During the analysis
step, data are critically explored and interpreted, significance of data is determined,
inferences are made and validated, signs and
symptoms and clusters of signs and symptoms are compared with the defining characteristics of nursing diagnoses, contributing factors are identified, and nursing
diagnoses are identified and organized in
order of priority.
3. This is not an example of the evaluation
step of the nursing process. Evaluation occurs when actual outcomes are compared
with expected outcomes that reflect goal
achievement.
4. This is an example of the implementation step of the nursing process. It is
during the implementation step that
planned nursing care is delivered.
8. 1. This action reflects the step of implementation. The nurse puts into action the plan
to monitor the client’s vital signs after a
cardiac event is suspected.
2. This action reflects the planning step of
the nursing process.
3. This action reflects the assessment
step of the nursing process. Assessment involves collecting data via
observation, physical examination,
and interviewing.
4. This action reflects the evaluation step
of the nursing process. The nurse assesses
the client’s respiratory rate and effort after
a nebulizer treatment to determine if the
treatment was effective in reducing airway
resistance, thereby improving the client’s
respiratory rate and reducing respiratory
effort.
9. 1. This goal is inappropriate because the
word “lower” is not specific, measurable,
or objective.
2. This is not a goal. This is an action the
nurse plans to implement to help a client
achieve a goal.
3. This is a well-written goal. Goals must
be client centered, specific, measurable, and realistic and have a time frame
in which the expected outcome is to be
achieved. The words “adequate” and
“dehydration” are based on generally
accepted criteria against which to
measure the client’s actual outcome.
The word “maintain” connotes continuously, which is a time frame.
4. This is not a goal. This is an action the
nurse plans to implement to help a client
achieve a goal.
10. 1. Setting time frames for goals to be achieved
is part of the planning, not evaluation, step
of the nursing process.
2. Revising a plan of care takes place in
the evaluation step of the nursing
process. If, during evaluation, it is
determined that the goal was not met,
the reasons for failure have to be identified and the plan has to be modified.
3. Determining priorities is part of the planning, not evaluation, step of the nursing
process. Priority setting is a decisionmaking process that ranks a client’s
nursing needs and nursing interventions
in order of importance.
4. Establishing outcomes is part of the planning, not evaluation, step of the nursing
process.
11. 1. This does not occur during the implementation step of the nursing process. During
the implementation step, the nurse puts
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
7745_Ch04_183-296 03/12/18 9:35 AM Page 193
CHAPTER 4 ESSENTIAL COMPONENTS
Copyright © 2019. F. A. Davis Company. All rights reserved.
the plan of care into action. Nursing
interventions include actions that are
dependent (requiring a primary healthcare provider’s prescription), independent
(autonomous actions within the nurse’s
scope of practice), and interdependent
(interventions that require a primary
health-care provider’s prescription but that
permit nurses to use clinical judgment in
their implementation).
2. This does not occur during the assessment
step of the nursing process. During the assessment step, the nurse uses various skills,
such as observation, interviewing, and
physical examination, to collect data from
various sources.
3. The identification of nursing actions
designed to help a client achieve a goal
occurs during the planning step of the
nursing process.
4. This does not occur during the analysis
step of the nursing process. The nurse
identifies the client’s human responses to
actual or potential health problems during
the analysis step of the nursing process.
12. 1. The defining characteristics are the
major and minor cues that form a cluster that supports or validates the presence of a nursing diagnosis. At least
one major defining characteristic must
be present for a nursing diagnosis to be
considered appropriate for the client.
2. Planned interventions do not support the
nursing diagnosis. They are the nursing
actions designed to help resolve the “related to” or “contributing to” factors and
achieve expected client outcomes that
reflect goal achievement.
3. The diagnostic statement cannot support
the nursing diagnosis because it is the first
part of the nursing diagnosis. A nursing
diagnosis is made up of two parts, the
diagnostic statement (also known as the
problem statement) and the “related to”
factors (also known as factors that contribute to the problem or the etiology).
4. Related risk factors cannot support the
nursing diagnosis because they are the second part of the nursing diagnosis. A nursing diagnosis is made up of two parts, the
diagnostic statement (also known as the
problem statement) and the “related to”
factors (also known as factors that contribute to the problem or the etiology).
13. 1. Although trust may be established during
the assessment phase of the nursing
OF
NURSING CARE
process, it is not the purpose of this step
of the nursing process. The development
of trust generally takes time.
2. The primary purpose of the assessment
step of the nursing process is to collect
data (information) from various sources
using a variety of approaches.
3. When a five-step nursing process is followed, formulating goals occurs during
the planning, not assessment, step of the
nursing process.
4. Validating the medical diagnosis is not
within a nurse’s legal scope of practice.
14. 1. Related factors (i.e., “contributing to”
factors, etiology) contribute to the
problem statement of the nursing diagnosis and directly have an impact on
the planning step of the nursing
process. Nursing interventions are
selected to minimize or relieve the
effects of the related factors. If nursing
interventions are appropriate and effective, the human response identified
in the problem statement part of the
nursing diagnosis will resolve.
2. The planning step of the nursing process
includes setting a goal, identifying the
outcomes that will reflect goal achievement, and planning nursing interventions.
Although the wording of the goal is
directly influenced by the diagnostic label
(problem statement of the nursing diagnosis), the selection of nursing interventions
is not.
3. Secondary factors generally have only a
minor influence on the planning step of
the nursing process.
4. The medical diagnosis does not influence
the planning step of the nursing process.
The nurse is concerned with human responses to actual or potential health
problems, not the medical diagnosis.
15. 1. Nursing care is planned after nursing
diagnoses and goals are identified, not
immediately after data are collected.
2. Goals are designed after a nursing
diagnosis is identified, not after data
are collected.
3. Once data are collected, the nurse must
first organize and cluster the data to determine significance and make inferences.
After all this is accomplished, then the
nurse can formulate a nursing diagnosis.
4. After data are collected, they are
clustered to determine their
significance.
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
193
7745_Ch04_183-296 03/12/18 9:35 AM Page 194
194
FUNDAMENTALS SUCCESS
Copyright © 2019. F. A. Davis Company. All rights reserved.
16. 1. If a thorough assessment was completed
initially, a reassessment should not be
necessary.
2. Establishing which of two nursing diagnoses is most appropriate is not dependent
on identifying the factors that contributed
to (also known as related to or etiology of)
the nursing diagnosis. These factors are
identified after the problem statement is
identified.
3. Establishing which of two nursing diagnoses is more appropriate is not dependent on analyzing the secondary to factors.
Secondary to factors generally are medical
conditions that precipitate the related
to factors. The secondary to factors are
identified after the related to factors of
the problem are identified.
4. The first thing the nurse should do to
differentiate between two closely associated nursing diagnoses is to compare
the data collected to the major and
minor defining characteristics of
each of the nursing diagnoses being
considered.
17. 1. Although completing a nursing physical
assessment includes an assessment of the
risk for falls, it is only one component of
the assessment.
2. Although completing a nursing physical
admission assessment includes an assessment of the skin, it is only one component
of the assessment.
3. This is the primary purpose of a nursing physical assessment. Data must be
collected and then analyzed to determine significance and be grouped in
meaningful clusters before a nursing
diagnosis or plan of care can be made.
4. Although completing a nursing physical
assessment helps to initiate the nurseclient relationship, it is not the primary
purpose of completing a nursing admission assessment.
18. 1. To evaluate the effectiveness of a
nursing action, the nurse must compare the actual client outcome with
the expected client outcome. The
expected outcomes are the measurable
data that reflect goal achievement, and
the actual outcomes are what really
happened.
2. The problem is associated with the first
half (problem statement) of the nursing
diagnosis, not the evaluation step of the
nursing process.
3. Etiology is a term used to identify the
factors that relate to or contribute to the
problem statement of the nursing diagnosis, not the evaluation step of the nursing
process.
4. Implementation is a step separate from
evaluation in the nursing process. Nursing
care must be performed before it can be
evaluated.
19. 1. This is not an example of the implementation step of the nursing process. It is during the implementation step that planned
nursing care is delivered.
2. This is not an example of the assessment
step of the nursing process. Although data
may be gathered during the assessment
step, the manipulation of the data is conducted in a different step of the nursing
process.
3. This is not an example of the evaluation
step of the nursing process. Evaluation occurs when actual outcomes are compared
with expected outcomes, which reflect
attainment or nonattainment of the goal.
4. During the analysis step of the nursing
process, data are critically explored
and interpreted, significance of data is
determined, inferences are made and
validated, cues and clusters of cues are
compared with the defining characteristics of nursing diagnoses, contributing factors are identified, and nursing
diagnoses are identified and organized
in order of priority.
20. 1. This is the correct analogy. The words
“identify” and “recognize” have the
same definition. They both mean the
same as that which is known. The
words “do” and “implement” both have
the same definition. They both mean
to carry out some action.
2. The words “identify” and “recognize”
have the same definition. They both mean
the same as that which is known. The
word “evaluate” does not fit the analogy
because the definitions of “evaluate” and
“do” are different. The word “evaluate”
means to determine the worth of something, whereas the word “do” means to
carry into effect or to accomplish.
3. The words “identify” and “recognize”
have the same definition. They both mean
the same as that which is known. The
word “analyze” does not fit the analogy
because the definitions of “analyze” and
“do” are different. The word “analyze”
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
7745_Ch04_183-296 03/12/18 9:35 AM Page 195
CHAPTER 4 ESSENTIAL COMPONENTS
Copyright © 2019. F. A. Davis Company. All rights reserved.
means to investigate the client’s human
response to an actual or potential health
problem. The word “do” means to carry
into effect or to accomplish.
4. The words “identify” and “recognize”
have the same definition. They both
mean the same as that which is known.
The word “plan” does not fit the analogy
because the definitions of “plan” and
“do” are different. The word “plan”
means a method of proceeding. The
word “do” means to carry into effect
or to accomplish.
21. 1. Observing is the deliberate use of all the
senses and involves more than just inspection and examination. It includes surveying, looking, scanning, scrutinizing, and
appraising. Although the nurse makes
inferences based on data collected by
observation, this is not as effective as
another data collection method to identify
subjective data associated with a client’s
anxiety.
2. Inspection involves the act of making
observations of physical features and
behavior. Although the nurse observes
behaviors and makes inferences based on
their perceived meaning, another data collection method is more effective in identifying subjective data associated with a
client’s anxiety.
3. Auscultation is listening for sounds within
the body. This collects objective, not
subjective, data, which are measurable.
4. Interviewing a client is the most
effective data collection method when
collecting subjective data associated
with a client’s anxiety. The client is
the primary source for subjective data
about beliefs, values, feelings, perceptions, fears, and concerns.
22. 1. Hoarseness may be a sign of laryngeal
inflammation as a result of microaspiration and should be clustered with
the group of signs presented in the
question.
2. Epigastric discomfort after eating (dyspepsia) may be symptom of a gastrointestinal
problem. Dyspepsia is unrelated to the
client’s clinical manifestations presented in
the question.
3. The body continuously secretes saliva
(approximately 1,000 mL/day) that
usually is swallowed. If a client is having difficulty swallowing, the client
may aspirate saliva, which can cause
OF
NURSING CARE
coughing. Coughing in addition to the
client’s other clinical manifestations
indicates that the client may have
impaired swallowing.
4. The body continuously secretes saliva
(approximately 1,000 mL/day) that
usually is swallowed. When saliva accumulates and is not swallowed, it dribbles out of the mouth (drooling).
Drooling in addition to the client’s
other clinical manifestations indicates
that the client may have impaired
swallowing.
5. The body continuously secretes saliva
(approximately 1,000 mL/day) that
usually is swallowed. When saliva accumulates and is not swallowed, it makes
a bubbling or gurgling sound in the
posterior oropharynx as air is inhaled
and exhaled.
6. A thin film of mucin, food debris, and
dead epithelial cells on the teeth (plaque)
is not related to the client’s other clinical
manifestations. Plaque is related to the
development of dental caries.
23. 4. Objective and subjective data must be
collected, verified, and communicated
during the assessment step of the
nursing process.
2. Data are clustered and analyzed, and
their significance is determined, leading to a conclusion about the client’s
condition, during the analysis step of
the nursing process.
3. Identifying goals, projecting outcomes,
setting priorities, and identifying interventions are all part of the planning
step of the nursing process.
5. Planned actions are initiated and completed during the implementation step
of the nursing process.
1. Identifying responses to care, comparing actual outcomes with expected outcomes, analyzing factors that affected
outcomes, and modifying the plan of
care if necessary are all part of the
evaluation step of the nursing process.
24. 1. This statement is not a goal. This is an action the nurse plans to implement to help
a client achieve a goal.
2. This goal is inappropriate because the
word “fewer” is not specific, measurable,
or objective.
3. This goal statement is incomplete. Although the statement is client-centered,
measurable, and realistic, it does not
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
195
7745_Ch04_183-296 03/12/18 9:35 AM Page 196
196
FUNDAMENTALS SUCCESS
include a time frame in which the
expected goal is to be achieved.
4. This statement is not a goal. This is an action the nurse plans to implement to help
a client achieve a goal.
5. This is a correctly worded goal. Goals
must be client-centered, measurable,
realistic, and include the time frame
in which the expected goal is to be
achieved. The words “one or no
events … daily” comprise a measurable
statement, and the words “within
6 weeks” establish a time frame.
Copyright © 2019. F. A. Davis Company. All rights reserved.
25. 1. A radial pulse is objective information.
Objective data are measurable and
checkable.
2. The sound of wheezing is objective
data because it can be heard by others.
Air becomes turbulent when it moves
through narrow passages that cause
vibration of airway walls, resulting
in high-pitched whistling sounds
(wheezing).
3. A temperature of 99°F is objective
information. Objective data are
measurable and can be verified.
4. Bradypnea is an example of objective
data. Objective data are measurable
and can be verified.
5. Vomiting is an example of objective
data. Objective data are measurable
and can be verified.
26. 1. The first step in the analysis phase of
the nursing process is to group and
cluster data that appear to have a
relationship. The nurse uses indicative
reasoning, moving from the specific to
the general.
5. The second step in analysis involves
gathering additional data to corroborate, substantiate, support, and validate
clustered data further.
3. The third step in analysis involves interpreting the data. The nurse uses
reasoning based on knowing commonalities and differences and a scientific
foundation of knowledge and experiential background to determine if the
data cluster is significant.
2. The fourth step in analysis involves the
nurse making a conclusion about the
clustered and validated data.
4. The fifth step in analysis involves
communicating conclusions to other
health team members in a nursing
plan of care.
27. 1. Knowing one’s own abilities is subjective information because it is the
client’s perception and can be verified
only by the client. Subjective data are
those responses, feelings, beliefs, preferences, and information that only the
client can confirm.
2. This statement is neither subjective nor
objective data. It is a statement indicating
an understanding of how to seek homecare services after discharge.
3. This statement is neither subjective nor
objective data. It is a question indicating
that the client wants more information
about how to control pain when at home.
4. This statement is neither subjective nor
objective data. It is a statement exploring
who will provide assistance with care once
the client goes home.
5. Fear is subjective information because
it is the client’s perception and can be
verified only by the client. Subjective
data are those responses, feelings, beliefs, preferences, and information that
only the client can confirm.
28. 1. Formulating a plan of care occurs during
the planning, not analysis, step of the
nursing process.
2. Potential risk factors are identified
during the analysis step of the nursing
process. Risk diagnoses are designed to
address situations in which clients have
a particular vulnerability to health
problems.
3. Determining which data are significant
or insignificant and then categorizing
the meaningful data into clusters of
data that are related are parts of the
analysis step of the nursing process.
4. This occurs during the planning, not
analysis, step of the nursing process.
5. This occurs during the evaluation, not
analysis, step of the nursing process.
29. 1. Hunger is an example of subjective, not
objective, data. Subjective data are those
responses, feelings, beliefs, preferences,
and information that only the client can
confirm.
2. Feeling warm is an example of subjective,
not objective, data. Subjective data are
those responses, feelings, beliefs, preferences, and information that only the client
can confirm.
3. The amount of food eaten by a client
can be objectively verified. The nurse
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
7745_Ch04_183-296 03/12/18 9:35 AM Page 197
CHAPTER 4 ESSENTIAL COMPONENTS
Copyright © 2019. F. A. Davis Company. All rights reserved.
measures and documents the percentage of a meal ingested by a client to
quantify the amount of food consumed.
4. A rash on a client’s arm can be objectively verified via inspection.
5. Having the urge to void is an example of
subjective, not objective, data. Subjective
data are those responses, feelings, beliefs,
preferences, and information that only the
client can confirm.
6. Vomiting is a human response that is
observable, and the amount vomited
can be measured. Vomiting is objective
information.
30. 1. This statement reflects the nurse using deductive reasoning. It moves from a general
premise (the client is dehydrated) to a specific deduction (the client will probably
have tenting of the skin, which is a sign of
dehydration).
2. This statement reflects the nurse using deductive reasoning. It moves from a general
premise (the client may have fractured the
head of the femur in the fall) to a specific
deduction (the client will probably have
pain in the hip if it is fractured).
3. This statement reflects the nurse using
inductive reasoning. It moves from the
specific to the general. A pattern of information (an elevated white blood cell
count and elevated temperature) leads
to a generalization (the client may have
an infection).
4. This statement reflects the nurse using
inductive reasoning. It moves from the
specific to the general. A pattern of information (crying, trembling, and a
rapid pulse) leads to a generalization
(the client may be anxious).
5. This statement reflects the nurse using deductive reasoning. It moves from a general
premise (the client is experiencing hypoglycemia) to a specific deduction (the client
OF
NURSING CARE
will probably have pale, cool, clammy skin
and a low blood glucose level).
31. 2. This statement reflects data collection
that occurs in the assessment phase
of the nursing process, which is the
first step.
3. This statement reflects etiological factors contributing to the nursing diagnosis problem statement, which is
“constipation.” This step analyzes the
data collected in the assessment phase
of the nursing process.
4. This statement is a measurable goal.
Identifying goals occurs after the
nursing diagnosis is identified.
1. This statement indicates implementation of a planned action that is designed
to address the problem statement.
5. Information about a client’s response
to nursing care can be used to compare
the client’s actual outcome with the expect outcome, which is the evaluation
phase of the nursing process.
32. 1. Feeling like vomiting is something that
only the client can perceive. Subjective
data are those responses, feelings,
beliefs, preferences, and information
that only the client can confirm.
2. This statement reflects objective, not
subjective, information. The urine is
observable and measurable. Objective data
can be verified.
3. A client’s perception about a level of
pain is subjective information. Subjective data are those responses, feelings,
beliefs, preferences, and information
that only the client can confirm.
4. This information reflects objective, not
subjective, data. The statement can be
verified.
5. This information reflects objective, not
subjective, data. The statement can be
verified.
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.
197
7745_Ch04_183-296 03/12/18 9:35 AM Page 198
198
FUNDAMENTALS SUCCESS
33.
Determining relationships of data and
their significance are associated with the
analysis phase of the nursing process.
Copyright © 2019. F. A. Davis Company. All rights reserved.
SIS
ALY
AN
34. 1. A productive cough is information collected during the assessment phase of the
nursing process.
2. This statement reflects an evaluation of
the client’s response to ambulation.
3. Seeking a prescription for chest physiotherapy reflects the planning phase of the
nursing process.
4. Administering a prescribed medication
reflects the implementation phase of the
nursing process.
35. 1. Nausea is an unpleasant, wavelike sensation in the back of the throat, epigastrium, or abdomen that may lead to
vomiting. It is considered subjective
data because it cannot be measured by
the nurse objectively. It is experienced
only by the client.
2. A yellow color of the skin, whites of the
eyes, and mucous membranes (jaundice)
because of deposition of bile pigments
from excess bilirubin in the blood is objective, not subjective, information. Objective
data are measurable and checkable.
3. Ecchymosis is objective data because it is
visible on the skin and is measurable and
checkable. It is a discoloration of the skin
caused by extravasation of blood into
subcutaneous tissue from ruptured blood
vessels near the surface of the skin. Ecchymosis can be caused by trauma, hematologic disease, or other medical conditions.
4. Excessive sweating (diaphoresis) is objective, not subjective, information. Objective
data are measurable and checkable.
5. Abnormally low systolic and diastolic
blood pressure levels (hypotension) can be
measured and verified and therefore are
objective data.
Nugent, Patricia, and Barbara Vitale. Fundamentals Success, 5th Ed : NCLEX-Style Q&a Review, F. A. Davis Company, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/austincc/detail.action?docID=5749977.
Created from austincc on 2021-03-08 20:17:36.