Chapter 05: Assessment, Nursing Diagnosis, and Planning

Chapter 05: Assessment, Nursing Diagnosis, and Planning

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

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               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 information about 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            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: 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: Basic Care and Comfort