Question 1

Which of the following best describes the difference between a medical diagnosis and a nursing diagnosis?

Accepted Answer

A nursing diagnosis describes problems that nurses can treat independently, while a medical diagnosis identifies diseases requiring physician intervention.

Question 2

A nurse is assessing a patient who reports severe abdominal pain, nausea, and vomiting. Which of the following is considered objective data?

Accepted Answer

The nurse observes the patient vomiting 400 ml at 0600.

Question 3

During the assessment phase of the nursing process, which method is used to determine the temperature, turgor, texture, and moisture of a patient's skin?

Accepted Answer

Palpation

Question 4

Which of the following is a correctly written, patient-centered, measurable short-term goal for a patient following hip surgery?

Accepted Answer

Patient will walk the length of the hallway twice this shift.

Question 5

A nurse is planning care for a patient with ineffective airway clearance. Which type of intervention is the nurse performing when teaching the patient how to use an incentive spirometer?

Accepted Answer

Nurse-initiated intervention

Question 6

Which of the following best illustrates the use of clinical reasoning during the assessment phase?

Accepted Answer

Systematically analyzing data, checking for accuracy, and distinguishing normal from abnormal findings.

Question 7

A nurse is evaluating a patient's progress toward a goal of 'demonstrating correct use of a blood glucose monitor by the end of the shift.' Which method is most appropriate for evaluation?

Accepted Answer

Observing the patient perform the skill.

Question 8

Which of the following is a common reason for patient noncompliance with a nursing intervention?

Accepted Answer

The patient lacks understanding about the benefits of the treatment.

Question 9

In the nursing process, which step involves determining whether the patient has achieved the expected outcomes and deciding whether to continue, modify, or terminate the plan of care?

Accepted Answer

Evaluation

Question 10

A nurse is preparing to discharge a patient. Which of the following is an essential component of ideal discharge planning?

Accepted Answer

Include the client and caregivers, address medications, home life, warning signs, test results, and educate about next steps.

Question 11

Which of the following is NOT a method of data collection during the assessment phase?

Accepted Answer

Diagnosis

Question 12

A nurse is using the Patient-Centered Assessment Method (PCAM). What is the primary purpose of this tool?

Accepted Answer

To assess patient complexity using determinants of health and environment.

Question 13

Which of the following variables may affect the implementation of a nursing care plan?

Accepted Answer

Patient's developmental stage and psychosocial background.

Question 14

A nurse is documenting a nursing diagnosis. Which of the following is a required component?

Accepted Answer

Defining characteristics (signs and symptoms)

Question 15

Which formula best represents the SMART criteria for writing nursing goals?

Accepted Answer

$$	ext{Specific} + 	ext{Measurable} + 	ext{Achievable} + 	ext{Relevant} + 	ext{Time-bound}$$

Question 16

A nurse is caring for a patient who refuses to ambulate due to fatigue and a sore leg. Which step of the nursing process should the nurse use to modify the care plan based on this response?

Accepted Answer

Evaluation

Question 17

Which of the following is an example of a collaborative problem in nursing?

Accepted Answer

Patient problem managed by both physician and nursing prescribed interventions.

Question 18

When evaluating the effectiveness of a nursing intervention, which of the following actions is most appropriate?

Accepted Answer

Ask the patient to repeat information or demonstrate a new skill.

Question 19

Which of the following is a key ethical responsibility for nurses regarding patient information?

Accepted Answer

Maintain the privacy of patients according to HIPAA requirements.

Question 20

A nurse is using critical thinking during the nursing process. Which of the following best demonstrates situational awareness?

Accepted Answer

Recognizing changes in the patient's status and anticipating potential complications.

The Nursing Process: Concepts, Assessment, and Clinical Judgment

Guida di studio - Domande di pratica

Study guide - Flashcard