Chapter 5: Nursing Process and Critical Thinking
Cooper and Gosnell: Foundations of Nursing, 7th Edition
MULTIPLE CHOICE
- 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.
DIF: Cognitive Level: Comprehension REF: Page OBJ: 1
TOP: Nursing process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
- 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.
DIF: Cognitive Level: Application REF: Page OBJ: 2
TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- 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.
DIF: Cognitive Level: Application REF: Page OBJ: 3
TOP: Subjective data KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- 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.
DIF: Cognitive Level: Application REF: Page OBJ: 3
TOP: Objective data KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- 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.
DIF: Cognitive Level: Comprehension REF: Page OBJ: 3
TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
- 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.
DIF: Cognitive Level: Comprehension REF: Page OBJ: 3
TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
- 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.
DIF: Cognitive Level: Comprehension REF: Page OBJ: 4
TOP: Nursing diagnosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- What framework does the establishment of priorities of care during the planning phase of the nursing process often use?
| a. | Erikson’s developmental tasks |
| b. | Piaget’s cognitive table |
| c. | Maslow’s hierarchy of needs |
| d. | Freud’s classifications |
ANS: C
A useful framework to guide prioritization is Maslow’s hierarchy of needs.
DIF: Cognitive Level: Comprehension REF: Page OBJ: 9
TOP: Priorities of care KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions?
| a. | The patient will increase intake to 1000 mL daily to liquefy secretions. |
| b. | The patient will cough more frequently within 3 days. |
| c. | The patient will breathe better within 3 days. |
| d. | The patient will perform deep-breathing exercises four times daily. |
ANS: A
The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within 3 days is too vague.
DIF: Cognitive Level: Comprehension REF: Page OBJ: 6
TOP: Nursing diagnosis KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- What is the primary purpose of nursing orders?
| a. | To support physician’s orders |
| b. | To provide direction for all caregivers |
| c. | To provide broad, general statements |
| d. | To clarify nursing principles |
ANS: B
Nursing orders are necessary to provide instructions for all caregivers.
DIF: Cognitive Level: Comprehension REF: Page OBJ: 7
TOP: Nursing orders KEY: Nursing Process Step: Planning
MSC: NCLEX: N/A
- What documentation reflects implementation?
| a. | “Patient selected low-sugar snacks independently.” |
| b. | “Patient was medicated with Tylenol 500 mg PO for pain.” |
| c. | “Patient was ambulated for 15 minutes after lunch.” |
| d. | “Patient participated in group therapy session without reminder.” |
ANS: C
Implementation is the nurse carrying out nursing orders to promote outcome achievement.
DIF: Cognitive Level: Comprehension REF: Page OBJ: 2
TOP: Implementation KEY: Nursing Process Step: Implementation
MSC: NCLEX: N/A
- Which nursing order is complete and correct?
| a. | “May 10: Nursing assistants will ambulate patient. A. Nurse” |
| b. | “Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse” |
| c. | “Nursing assistants will serve 8 oz glass of juice at each meal, 5/10.” |
| d. | “P.M. nurse will ensure that heel protectors are in place before bedtime.” |
ANS: B
Nursing orders must be signed, dated, and have specific designation as to who will perform intervention and specifics about time or frequency of the intervention.
DIF: Cognitive Level: Application REF: Page OBJ: 7
TOP: Nursing orders KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred?
| a. | Omission |
| b. | Variance |
| c. | Failure |
| d. | Error |
