Question 1

Which of the following best describes the purpose of the assessment phase in the nursing process?

Accepted Answer

To establish a database about the client's health status, needs, and challenges in order to address them.

Question 2

A nurse observes a patient crying and concludes the patient is sad due to hospitalization. What critical step should the nurse take before making this inference?

Accepted Answer

Validate the inference by directly asking the patient about the reason for crying.

Question 3

Which of the following is an example of subjective data collected during the assessment phase?

Accepted Answer

A patient states, 'I feel dizzy.'

Question 4

A nurse measures a patient's oxygen saturation and notes it is $$92\%. $$What type of data is this?

Accepted Answer

Objective data

Question 5

Which of the following is considered a primary source of data in the nursing assessment?

Accepted Answer

The patient themselves

Question 6

A nurse is reviewing a patient's chart, speaking with family members, and reading lab reports. What type of data sources are these?

Accepted Answer

Secondary sources

Question 7

Which of the following best illustrates the concept of clustering data in the nursing process?

Accepted Answer

Grouping signs and symptoms such as vomiting and diarrhea to identify fluid loss.

Question 8

A nurse notes that a patient vomits every time after taking medication. What is this an example of in the data analysis process?

Accepted Answer

Identifying a pattern

Question 9

Which of the following is a correct statement about the difference between a nursing diagnosis and a medical diagnosis?

Accepted Answer

A nursing diagnosis focuses on the client's response to health problems, while a medical diagnosis identifies a specific disease or condition.

Question 10

Which of the following is an example of an actual nursing diagnosis according to NANDA-I format?

Accepted Answer

Activity intolerance related to abdominal pain following surgery, as evidenced by inability to walk.

Question 11

A nurse is writing a risk nursing diagnosis. Which components must be included?

Accepted Answer

Potential problem and related factors

Question 12

Which of the following is a defining characteristic in a nursing diagnosis?

Accepted Answer

Cluster of signs and symptoms that indicate the problem exists

Question 13

A nurse is analyzing assessment data and notices missing information about the patient's age and family history. What is this an example of?

Accepted Answer

Identifying data gaps

Question 14

Which of the following actions best demonstrates data validation in nursing assessment?

Accepted Answer

Comparing subjective and objective data to ensure they agree

Question 15

A nurse is using inspection, palpation, auscultation, and percussion during a physical assessment. What is the nurse doing?

Accepted Answer

Examining the patient using systematic techniques

Question 16

Which of the following is a common source of diagnostic error in nursing?

Accepted Answer

Errors in data collection, interpretation, clustering, or diagnostic statements

Question 17

A nurse is comparing a patient's blood pressure of $$150/80$$ mmHg to normal adult values. What step of data analysis is this?

Accepted Answer

Comparing data to norms or standards

Question 18

Which of the following best describes the role of NANDA-I in nursing practice?

Accepted Answer

Provides standardized terminology for nursing diagnoses to maintain consistency among nurses internationally.

Question 19

A nurse is caring for a patient who states, 'I am cold,' and is observed shivering with a temperature of $$37.2^\circC. $$Which statement is true regarding the data collected?

Accepted Answer

The nurse has collected both subjective and objective data.

Question 20

Which of the following is an example of a health promotion nursing diagnosis?

Accepted Answer

Readiness for enhanced knowledge regarding foods rich in iron

Nursing Process: Assessment and Diagnosis – Structured Study Notes

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