Chapter 03: The Nursing Process and Standards of Practice

Chapter 03: The Nursing Process and Standards of Practice

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. The patient asks the nurse, “I’ve heard the student nurses talk about the nursing process. Why is there so much emphasis on using the nursing process?” The response that explains the need for nurses to understand and use the nursing process is:

ANS: B

This response best explains the importance of the nursing process by description and relationship to patient care. Suggesting that the patient may have a better method is challenging and does not address the question posed by the patient. Providing legitimacy to the profession is a very limited explanation for use of the nursing process. The nursing process is not one-dimensional, static, or linear.

DIF:   Cognitive Level: Knowledge        REF:  Page 40

TOP:  Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

2. When preparing to conduct a nursing history and assessment on a patient transferred from the emergency department (ED) whose family believes the patient to be a questionable historian due to cognitive impairment, the nurse initially begins the interview by:

ANS: D

The nurse should begin establishing the nurse–patient relationship by initially directing the questions to the patient. The nurse can confirm information and/or obtain supplementary information from the sources identified by the other options.

DIF:   Cognitive Level: Application        REF:  Page 40

TOP:  Nursing Process: Assessment        MSC: NCLEX: Safe and Effective Care Environment

3. The nurse shows the ability to effectively state a nursing diagnosis reflective of the implications of depression on a patient’s life processes when stating in the patient’s plan of care that:

ANS: D

This statement contains the various components of a nursing diagnosis while expressing the existence of an altered life process. The remaining options reflect other steps, such as evaluation and intervention planning.

DIF:   Cognitive Level: Application        REF:  Pages 47-48   TOP:  Nursing Process: Analysis

MSC: NCLEX: Safe and Effective Care Environment

4. When engaging in outcomes identification, the nurse:

ANS: C

Outcomes are projections of expected influence that nursing interventions will have on the patient. Interviewing and collecting data is involved in the assessment process, re-assessing is involved in the evaluation process, and identifying related nursing problems is involved in determining appropriate nursing diagnoses.

DIF:   Cognitive Level: Application        REF:  Page 49

TOP:  Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

5. While discussing assessment of suicidal patients, a novice nurse mentions, “I was taught to always base my care on concrete, evidence-based scientific reasoning and never to rely on intuition.” Which response by the experienced nurse shows understanding of intuitive reasoning?

ANS: C

A “strong hunch” or a “gut feeling” is an example of intuitive reasoning that is believed to come from the therapeutic relationship’s sharing of feelings between nurse and patient. Most nurses agree that intuition is compatible with scientific reasoning, because both are likely linked to practice and experience. A nurse learns intuitive reasoning through clinical practice rather than from school or books.

DIF:   Cognitive Level: Application        REF:  Page 45

TOP:  Nursing Process: Analysis (Caring)

MSC:   NCLEX: Safe and Effective Care Environment