Chapter 09: Nursing Process

Chapter 09: Nursing Process

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained. The nurse is currently involved in which step of the nursing process?

ANS:   A

Assessment is the deliberate and systematic collection of data about a patient. The data will reveal a patient’s current and past health status, functional status, and present and past coping patterns. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Implementation is the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care. Evaluation is crucial to deciding whether, after interventions have been delivered, a patient’s condition or well-being improves.

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    124                  OBJ:    Describe each step of the nursing process.

TOP:    Nursing Process: Assessment            MSC:   NCLEX: Management of Care

2. The nurse is admitting a patient to the unit and asks the patient about the health history. The nurse is engaged in which component of the nursing process?

ANS:   C

The nurse is in the assessment phase. An assessment database includes a patient’s comprehensive health history, which includes information about a patient’s physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system. The database also includes physical examination findings and a summary of results from laboratory and diagnostic testing. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Evaluation is crucial to deciding whether, after interventions have been delivered, a patient’s condition or well-being improves. Planning involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions.

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    124                  OBJ:    Discuss approaches to data collection in nursing assessment.

TOP:    Nursing Process: Assessment            MSC:   NCLEX: Management of Care

3. A postoperative patient is continuing to have incisional pain. As part of the nurse’s assessment, the nurse notes that the patient is grimacing when he or she changes position. The patient’s grimace can be useful in the assessment and can be described as which of the following?

ANS:   A

Grimacing is a cue. A cue is information that a nurse obtains through use of the senses. An inference is your judgment or interpretation of these cues. Gordon’s functional health patterns are a type of database format to obtain a comprehensive assessment. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat.

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    125                  OBJ:    Explain the type of conclusions that result from data analysis.

TOP:    Nursing Process: Assessment            MSC:   NCLEX: Management of Care

4. A postoperative patient has denied the need for pain medication. The nurse has noted that the patient describes the pain as a “1” on a 0 to 10 scale. The nurse also notes that the patient grimaces when he or she changes position and guards the incision. The nurse believes that the patient is experiencing pain based on the information gathered in the assessment. What is this phenomenon known as?

ANS:   B

The nurse made a judgment, which is an inference, that the patient is experiencing pain. An inference is a nurse’s judgment or interpretation of a cue. A cue is information that you obtain through use of the senses. Gordon’s functional health patterns are a type of database format to obtain a comprehensive assessment. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat such as impaired tissue perfusion.

PTS:    1                      DIF:    Cognitive Level: Applying (Application)

REF:    125                  OBJ:    Explain the type of conclusions that result from data analysis.

TOP:    Nursing Process: Assessment            MSC:   NCLEX: Management of Care