2.
Place the steps of the problem-solving approach in the
appropriate order:
Test Bank For Dewits Fundamental Concepts And Skills For
Nursing 5th Edition By Williams 58
a.
b.
c.
d.
e.
Predict the likelihood of each outcome occurring.
Choose the alternative with the best chance of success.
Consider all possible alternatives as the solution to the
problem.
Identify the problem.
Examine possible outcomes of each alternative.
ANS:
D, C, E, A, B
The problem-solving approach requires that a problem be clearly identified, all possible
alternative solutions be examined, outcomes of solutions be considered, probability of outcome
occurring be predicted, and the best alternative be chosen.
DIF:
Cognitive Level: Knowledge REF: p. 50
OBJ: Theory #4 TOP: Problem Solving
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
Test Bank For Dewits Fundamental Concepts And Skills For Nursing 5th Edition By Williams
59
Chapter 05 : Assessment, Nursing Diagnosis, and Planning
MULTIPLE CHOICE
1.
When the patient complains of nausea and dizziness, the nurse recognizes these
complaints as
data.
a.
objective
b.
medical
c.
subjective
d.
adjunct
ANS: C
Subjective data are symptoms that only the patient can identify.
DIF:
Cognitive Level: Application REF: p. 58
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OBJ: Theory #3 TOP: Assessment Data
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic
Care and Comfort
2.
The major goal of the admission interview (usually performed by the RN) is to:
a.
establish rapport.
b.
help the patient understands the objectives of care.
c.
identify the patient‘s major complaints.
d.
initiate nursing care plan forms.
ANS: C
The interview is used as part of the assessment process to elicit informationabout the patient‘s
physical, emotional, and spiritual health.
DIF:
Cognitive Level: Comprehension
REF: p. 58
OBJ: Theory #1 TOP: Interview
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
3.
An example of a structured format for gathering data that aids in forming a database is:
a.
North American Nursing Diagnosis Association–International (NANDA-I).
b.
Maslow‘s hierarchy.
c.
QSENl
d.
Gordon‘s 11 Health Patterns.
ANS: D
Mary Gordon‘s assessment guide is a guided path to cover 11 health points. Although Maslow
may be used, it is not structured.
DIF: Cognitive Level: Knowledge REF: p. 58|Box 5-1
OBJ: Theory # 2
TOP: Gordon‘s 11 Health Patterns
MSC: NCLEX: N/A
KEY: Nursing Process Step: N/A
4.
During the assessment phase of the nursing process, the nurse:
a.
develops a care plan to meet the patient‘s nursing needs.
b.
begins to formulate plans for providing nursing intervention.
c.
establishes a nursing diagnosis for the nursing care plan.
d.
gathers, organizes, and documents data in a logical database.
ANS: D
Gathering and organizing data is the first step in the assessment phase of the nursing process.
DIF: Cognitive Level: Comprehension
REF: p. 58
OBJ: Theory #1 TOP: Data
Collection
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
5.
After the admission assessment is completed, on subsequent shifts or days, the nurse:
a.
does not assess the patient again unless the condition changes.
b.
refers only to the admission assessment during the hospitalization.
c.
performs a complete physical examination every day.
d.
assesses the patient briefly in the first hour of the shift.
ANS: D
The patient should be briefly assessed at the beginning of each shift and more thoroughly if his
or her condition changes or as per the plan of care.
DIF: Cognitive Level: Comprehension
REF: p. 70 OBJ: Theory #1 TOP: Physical
Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity:
51
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Basic Care and Comfort
6.
The nurse performing an admission interview on an older adult person should:
a.
rush through the interview to avoid tiring the patient.
b.
direct questions to the family rather than the patient.
c.
allow more time for a response to questions.
d.
prompt the patient to speed recall.
ANS: C
When interviewing an older adult person, allow more time because the person will probably have
a more extensive history and may take a little longer to recall the needed information.
DIF:
Cognitive Level: Application REF: p. 59
OBJ: Theory #5 TOP: Admission Interview
KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity: Basic
Care and Comfort
7.
A nursing diagnosis consists of:
a.
the health care provider‘s medical diagnosis listed as the nursing diagnosis.
b.
diagnostic labels formulated by the North American Nursing Diagnosis Association–
International (NANDA-I).
c.
the patient‘s explanation of his or her ―chief complaintǁ or ―current complaint.ǁ
d.
the results of the nursing assessment without consideration of doctor‘s orders.
ANS: B
NANDA-I has formulated an official list of nursing diagnoses to identify patient problems and
problems that patients are at risk of developing. A nursing diagnosis is independent of a medical
diagnosis.
DIF: Cognitive Level: Comprehension
REF: p. 65
OBJ: Theory #5 TOP: Nursing
Diagnosis
KEY: Nursing Process Step: Planning MSC: NCLEX: N/A
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8.
An older adult patient with a medical diagnosis of chronic lung disease has developed
pneumonia. She is coughing frequently and expectorating thick, sticky secretions. She is very
short of breath, even with oxygen running, and she is exhausted and says she ―can‘t breathe.ǁ
Based on this information, an appropriately worded nursing diagnosis for this patient is:
a.
Airway clearance, ineffective, related to lung secretions as evidenced by cough and
shortness of breath.
b.
Pneumonia, cough, and shortness of breath related to chronic lung disease.
c.
Difficulty breathing not relieved by oxygen and evidenced by shortness of breath.
d.
Cough and shortness of breath caused by pneumonia, chronic lung disease, advanced age,
and exhaustion.
ANS: A
The nursing diagnosis from the NANDA list is complete with a cause and signs and symptoms.
DIF: Cognitive Level: Analysis REF: p. 66|Box 5-4 OBJ: Theory #5
Diagnosis
KEY: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
TOP: Nursing
9.
If a patient has several nursing diagnoses, the nurse will first:
a.
consult with the doctor regarding which diagnosis is most important.
b.
devise nursing interventions for the most quickly solved problems.
c.
prioritize the nursing problems according to Maslow‘s hierarchy of needs.
d.
review the patient‘s medical prescriptions and other drugs being taken.
ANS: C
Nursing diagnoses (and thus their interventions )must be prioritized to identify the order
of importance based on Maslow‘s hierarchy.
DIF:
Cognitive Level: Analysis
REF: p. 65
KEY: Nursing Process Step: Planning
OBJ: Clinical Practice #4 TOP: Prioritizing
MSC: NCLEX: N/A
10.
A patient has a nursing diagnosis of imbalanced nutrition: less than body requirements,
related to mental impairment and decreased intake, as evidenced by increasing confusion and
weight loss of more than 30 pounds over the last 6 months. An appropriate short-term goal for
this patient is to:
a.
eat 50% of six small meals every day by the end of 1 week.
b.
demonstrate progressive weight gain over 6 months.
c.
eat all of the meals prepared during admission.
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d.
verbalize understanding of caloric needs and intention to eat.
ANS: A
Short-term goals should be realistic and attainable and should have a timeline of 7 to 10 days
before discharge.
DIF: Cognitive Level: Application REF: p. 66
OBJ: Clinical Practice #6 TOP: Expected
Outcomes
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
11.
The nursing diagnoses that has the highest priority is:
a.
Mobility, impaired physical, related to muscular weakness as evidenced by the
inability to walk without assistance.
b.
Communication, impaired verbal, related to neuromuscular weakness as evidenced by
facial weakness and inability to speak.
c.
Imbalanced nutrition: less than body requirements, related to difficulty swallowing and
inadequate food intake as evidenced by weight loss of 10 pounds.
d.
Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking
and coughing while eating.
ANS: D
Choking and aspiration are life-threatening events and take priority over problems such as
weakness, inability to speak, or weight loss.
DIF:
Cognitive Level: Analysis
REF: p. 65
OBJ: Clinical Practice #4 TOP: Prioritizing
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12.
A patient with visual impairment is identified as at-risk for falls related to blindness. An
appropriate intervention would be:
a.
assist the patient with feeding herself at the end of the meal.
b.
arrange furnishings in room to provide clear pathways and orient the patient to these.
c.
take the patient‘s blood pressure before she gets up in the morning.
d.
report any falls immediately to the charge nurse and the doctor.
ANS: B
Providing clear pathways directly reduces the risk of patient falls.
DIF: Cognitive Level: Analysis NURSINRGETFB:.CpO.M62
OBJ: Clinical
Practice #6 TOP: Clinical Planning
KEY: Nursing Process Step: Planning
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MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
13.
The North American Nursing Diagnosis Association–I (NANDA-I) list is revised and
updated every:
a.
year.
b.
2 years.
c.
3 years.
d.
5 years.
ANS: B
NANDA-I meets every 2 years to revise and update the list.
DIF: Cognitive Level: Knowledge REF: p. 65 OBJ: Theory #5 TOP: NANDA I
Nursing Process Step: N/A MSC: NCLEX: N/A
KEY:
14.
A nursing care plan consists of:
a.
nursing orders for individualized interventions to assist the patient to meet expected
outcomes.
b.
orders for diagnostic and therapeutic procedures such as laboratory tests or radiographs.
c.
the health care provider‘s history and physical examination, as well as medical diagnoses.
d.
laboratory and radiograph reports, pathology reports, and the medication record.
ANS: A
The nursing care plan consists of the nursing orders for interventions to address problems and
establish outcomes by which the plan can be evaluated.
DIF: Cognitive Level: Comprehension
REF: p. 69
OBJ: Clinical Practice #5 TOP:
Nursing Care Plan
KEY: Nursing Process Step: Planning
MSC: NCLEX: N/A
15.
In an acute care facility, a nursing care plan is usually reviewed and updated:
a.
every shift.
b.
every 24 hours.
c.
once every 3 days.
d.
on admission and discharge.
ANS: B
Ongoing assessment, intervention, and evaluation lead to attainment or modification of the
original plan for the patient who is acutely ill. The nursing care plan must be updated every day
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to reflect these changes.
DIF: Cognitive Level: Knowledge REF: p. 69
OBJ: Clinical Practice #6 TOP: Nursing
Care Plan
KEY: Nursing Process Step: Planning
MSC: NCLEX: N/A
16.
The nurse takes into consideration that the difference between a sign and a symptom is
that a sign is:
a.
subjective data.
b.
unreliable because it depends NonURtrSaInNsGlaTtBio.Cn.OM
c.
can be verified by examination.
d.
something a patient reports that is verified by a relative.
ANS: C
Signs are objective data that can be confirmed by examination, assessment, or observation. Signs
are reliable research-based data.
DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #2 TOP: Assessment
(Data Collection) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological
Integrity: Basic Care and Comfort
17.
The nurse clarifies that nursing orders are also called:
a.
goals.
b.
qualifiers.
c.
interventions.
d.
measurement criteria.
ANS: C
Nursing orders are also called nursing interventions and follow the same requirements when
placed in a nursing care plan.
DIF:
Cognitive Level: Knowledge REF: p. 64
OBJ: Theory #2 TOP: Nursing Orders
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
18.
The nurse designs the goals for patients in long-term facilities to be:
a.
conditional.
b.
open ended.
c.
based on behavioral norms.
d.
long term.
ANS: D
Long-term goals are more appropriate for patients in long-term facilities because they will be
there for an extended period and many of their health problems are chronic.
DIF: Cognitive Level: Comprehension
REF: p. 69
OBJ: Theory #7 TOP: Long Term
Goals KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care
and Comfort
19.
a.
b.
c.
d.
Standardized Nursing Care Plans can:
be documented without alteration.
have items altered or deleted.
become part of the record without documentation.
help the family understand the concept of Nursing Care Plans.
51
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ANS: B
Standardized Nursing Care Plans are generic and need to be altered to become individualized.
They must be documented.
DIF: Cognitive Level: Comprehension
REF: p. 69
OBJ: Theory #7 TOP: Assessment
(Data Collection)
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
20.
A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia.
The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has
audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is:
a.
Airway clearance, ineffective, related to retained secretions as evidenced by
expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the
base of the right lung.
b.
Airway clearance, ineffective, related to right lower lobe pneumonia as evidenced by
expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the
base of the right lung.
c.
Right lower lobe pneumonia, related to airway clearance, ineffective, as evidenced by
expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the
base of the right lung.
d.
Expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles
in the base of the right lung related to right lower lobe pneumonia as evidenced by airway
clearance.
ANS: A
The nursing diagnosis is from the NANDA-I list and is complete with a cause and signs and
symptoms. The other answers contain a medical diagnosis of pneumonia, which is inappropriate.
DIF: Cognitive Level: Analysis
REF: p. 65
KEY: Nursing Process Step: Diagnosis
OBJ: Theory #7 TOP: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
21.
Reginald is a nurse caring for a 56-year-old man who is admitted with an acute MI. As he
completes the initial assessment, he knows that concerning the practice of nursing, the purpose of
the assessment on admission is to:
a.
gather data so that the patient‘s response to the treatment can be evaluated.
b.
gather data for the health care provider, to make decisions based on the condition of the
patient.
c.
establish rapport with the patient so that he/she can feel safe and secure in the acute
health care setting.
d.
begin the care plan and set the patient on the road to recovery.
ANS: A
The practice of nursing is concerned with how a patient responds, physiologically and
psychologically, to their disease or disorder, to their treatment(s), their life situation and
environment, etc. In order to determine this, a database containing information about the patient
must be established. It is in this capacity that LPN/LVNs contribute, via data collection, to the
assessment stage of the nursing process.
DIF: Cognitive Level: Comprehension
REF: p. 58
OBJ: Theory #1 TOP: Assigning
Admission Tasks
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
22.
Theresa is a nurse caring for a 14-year-old girl who is admitted with an asthma attack.
51
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When she writes the nursing diagnosis statement she includes?
a.
Two statements; the problem and the signs and/or the symptoms.
b.
The medical diagnosis.
c.
Her clinical judgment regarding the patient‘s response to the problem.
d.
Uses the NANDA-I as the stem and the medical diagnosis as the conclusion.
ANS: C
Most care facilities use a problem statement in care planning that may (or may not) conform to
the NANDA-I terminology. Whatever the terminology used, the nursing diagnosis reflects the
nurse‘s clinical judgment regarding the patient‘s response to an actual or potential health
problem, and is the basis for the nurse‘s plan of care for the patient.
DIF: Cognitive Level: Comprehension
REF: p. 65 OBJ: Theory #5
TOP: Nursing Diagnosis
KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX:
N/A
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MULTIPLE RESPONSE
1.
The nurse understands that an expected outcome should be: (Select all that apply.)
a.
realistic.
b.
approved by the health care provider.
c.
attainable.
d.
within a defined time.
e.
included after patient collaboration.
ANS: A, C, D, E
An expected outcome should be realistic and attainable and should have a defined time line after
collaboration with the patient.
DIF: Cognitive Level: Knowledge REF: p. 67
OBJ: Theory #6 TOP: Nursing Process
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care
and Comfort
2.
A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility
related to neurological impairment and muscular weakness. Appropriate interventions for this
patient would include which of the following? (Select all that apply.)
a.
Assist with range of motion exercises every 4 hours and as needed.
b.
Instruct patient to call for assistance when needing to get out of bed.
c.
Apply wrist and ankle restraints to promote safety and prevent falls.
d.
Teach about exercises that will strengthen muscles while lying in bed.
e.
Ambulate with physical therapy assistance at least three times a day.
ANS: A, B, D, E
The nurse selects appropriate nursing interventions to alleviate the problems and assist the
patient in achieving the expected outcomes. Consider all possible interventions for relief of the
problems and then select those most likely to be effective.
DIF:
Cognitive Level: Application REF: p. 68
OBJ: Clinical Practice #5 TOP: Assessment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3.
a.
b.
Appropriate nursing roles in the initial assessment would include: (Select all that apply.)
LPN obtains the vital signs of a new patient.
RN performs a complete physNicUalRaSsINseGsTsmB.eCnOtM.
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