Exam (elaborations)
Chapter 5 Nursing Process and Critical Thinking
- Course
- Nursing
- Institution
- Western Piedmont Community College
Chapter 5 Nursing Process and Critical Thinking
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Chapter 5: Nursing Process and Critical ThinkingMULTIPLE CHOICE
1. What best defines the nursing process?
a. A method to ensure that the physician‘s orders are implemented correctly.
b. A series of assessments that isolate a patient‘s health problem.
c. A framework for the organization of individualized nursing care.
d. A preset formula for the design of nursing care.
ANS: C
The nursing process is a framework by which to organize individualized nursing care.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 78
OBJ: 1 TOP: Nursing process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. All of the following patients have been admitted to the acute care setting. On admission,
which patient should receive a focused assessment?
a. 53-year-old admitted with a perforated ulcer
b. 5-year-old admitted for the implant of grommets in the middle ear
c. 76-year-old admitted for a knee replacement
d. 40-year-old admitted for possible bowel obstruction
ANS: A
A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should
receive a focused assessment. The remaining options are not considered critical illnesses.
PTS: 1 DIF: Cognitive Level: Application REF: Page 79
OBJ: 2 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3. What subjective data does the nurse record following a head-to-toe examination?
a. Rash on back
b. Prolonged nausea
c. Blood pressure of 190/100
d. White blood cell count of 19,000
ANS: B
Another term for subjective data is symptoms, which cannot be observed or measured. This
data must come from the patient.
PTS: 1 DIF: Cognitive Level: Application REF: Page 79
OBJ: 3 TOP: Subjective data
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. What objective data should the nurse include after a patient assessment?
a. Headache of 3 days duration
b. Severe stomach cramps
c. Flatulence
, d. Anxiety
ANS: C
Objective data are observable and measurable by people other than the patient.
PTS: 1 DIF: Cognitive Level: Application REF: Page 79
OBJ: 3 TOP: Objective data
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. What is classified as information provided by the family when a patient is unable to provide
data during assessment?
a. Primary
b. Secondary
c. Unreliable
d. Biased
ANS: B
Secondary sources include family members.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 79-80
OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
6. What are the two primary methods used to collect data?
a. Written report by patient and family
b. Review of the chart and the nurse‘s notes
c. Interview and physical examination
d. Review of the physician‘s orders and the Kardex
ANS: C
The two primary methods of collecting data are interviewing and physical examination.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 79-80
OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
7. The nurse writes two nursing diagnoses: (1) inadequate nutritional intake related to vomiting
as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to
inadequate nutrition. What is the major difference between these diagnoses?
a. The second diagnosis needs no defined nursing interventions.
b. The second diagnosis needs medical intervention.
c. The second diagnosis will not need to be evaluated.
d. The second diagnosis reflects a problem that does not yet exist.
ANS: D
The actual nursing diagnosis represents a condition that is currently present. ―Risk for‖
diagnoses are those that the patient is susceptible to, but not yet troubled by.
PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 81-83
OBJ: 4 TOP: Nursing diagnosis
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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