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a) Assessment
b) Diagnosis
c) Planning
d) Implementation
1. The nurse is measuring the client’s urine output and straining the urine to assess for
stones. Which of the following should the nurse record as objective data?
a) The client reports abdominal pain- subjective
b) The client urine output was 450ml
c) The client’s states, “ I didn’t see any stones in my urine.”
d) The client’s states, “I feel like I have passed a stone.”
2. When evaluating an elderly client’s blood pressure of 145/80mmHg, the nurse does which
of the following before determining whether the Bp is normal or represents hypertension?
a) Compare this reading against defined standards
b) Compare the reading with one taken in the opposite arm
c) Determine gaps in the vital signs data in the client record.
d) Compare the current measurement with previous ones
3. The nurse performs an assessment of a newly admitted patient. The nurse understands
that this admission assessment is conducted primarily to:
a) Diagnose if the patient is at risk for falls
b) Ensure that the patient’s skin is intact
c) Establish a therapeutic relationship
d) Identify important data
4. The nurse understands that evaluation most directly relates to which aspect of the nursing
process?
a) Goal
b) Problem
c) Etiology
d) Implementation
5. The nurse comes to the conclusion that a patient’s elevated temperature, pulse and
respiration are significant. What step of the nursing process is being used when the nurse
comes to this conclusion?
a) Implementation
b) Assessment
c) Evaluation
d) Diagnosis
6. When the nurse considers the Nursing Process, the word “identify” is to “recognize” as the
word “do” is to?
a) Plan
b) Evaluate
c) Diagnose
d) Implement-
7. The nurse is collecting subjective data associated with a patient’s anxiety. Which
assessment method should be used to collect this information?
a) Observing
b) Inspecting
c) Auscultation
d) Interviewing
9. During which of the five steps in the Nursing Process does the nurse determine whether
outcomes of care are achieved?
a) Implementation
b) Evaluation
c) Diagnosis
d) Planning
10.When considering the nursing process, the nurse understands that the word “observe” is
to “assess” as the word “determine” is to?
a) Plan
b) Analyze
c) Diagnose
d) Implement
15.An example of an approved, correctly written nursing diagnosis for the patient is:
a) Pain r/t abdominal surgery as evidenced by surgical report
b) Risk for injury r/t neurological impairment as evidenced by paralysis of right leg
c) Risk for fluid deficit r/t nausea and vomiting
d) Constipation r/t complaint of no Bowel movement yesterday
16.Mhy ‘s temperature is 100.4 Fahrenheit. The skin on her forehead is warm and dry. She has
been incontinent and her bed is wet. She is complaining of being tired. Which of the data
is subjective?
a) Temperature 100.4 Fahrenheit
b) Skin warm and dry
c) Bed is wet
d) Complains of being tired
17.You want to know something about the patient’s spirituality. You would first look for any
noted religious preference:
a) In the nursing assessment
b) On the face sheet
c) In the physician’s history and physical
d) On the physical examination form
18.Which one of the following is stated as a goal rather than an expected outcome?
a) Patient will resume full job activities within 3 weeks
b) Patient will perform exercises three times a day
c) Patient will regain use of left arm and leg
d) Physical therapist will instruct patient in use of walker before discharge
20.The establishment of data base for a newly admitted patient forms which phase of the
nursing process?
a) Assessment
b) Implementation
c) Diagnosing
d) Planning
21.Assessment phase of the nursing process is completed:
a) At the beginning of every shift
b) In the terminating phase of the nurse-patient relationship
c) On the initial nurse-patient relationship
d) At the beginning and end of each shift
22.A nurse who is taking care of a patient with severe dehydration decided to first provide
liquids and gave health instructions on sanitation and hygiene. What is the nurse doing in
the element of nursing process?
a) Implementations
b) Evaluation
c) Planning
d) Assessment
23. It is the comprehensive approach of collecting data to identify possible nursing problems
is processed through?
a) Assessment
b) Evaluation
c) Analysis
d) Nursing diagnosis
24.In taking care of patients for cardiac catheterization, the nurse noted that the patient
manifested fear related to cardiac catheterization and its outcome, this statement is an
example of:
a) Nursing diagnosis
b) Implementation
c) Evaluation
d) Intervention
26.Through the course of Jack’s interaction with the family, he learned that the couple has 6
children, 2 of which are in the secondary, 3 in the elementary and the three-year old baby
stays at home. In addition, he learned that the family’s income is about P400/day. Jack is
utilizing what type of assessment?
a) Interview
b) Record Review
c) Observation
d) Physical Assessment
27.When Jack roamed around the community to visit other families, one of the mothers
approached him and told him that her child is having colds and fever. Jack examined the
child and took the child’s vital signs. Jack utilizes which of the following types of data
gathering?
a) Observation
b) Laboratory examination
c) Record review
d) Physical assessment
30.During his immersion with Aling Isabella’s family, Edward learned that she has 5 children,
1 is in the secondary, 3 in the elementary and a three-year old baby. He also found out in
their conversation that her daily income for doing laundry is 250php/day. What technique
did Edward perform in gathering data?
a. Inquiry Forms
b. Interview
c. Observation
d. Physical Assessment
31.Edward also noticed that Aling Isabella’s three year-old baby has colds and fever. He
examined the child and took the vital signs. Edward’s action is an example of?
a. Physical Assessment
b. Observation
c. Interview
d. Record review
32.Edward went back to the health center to retrieve the interview questionnaire answered
by the family. Jack is utilizing which type of data gathering?
a. Observation
b. Physical assessment
c. Record review
d. Interview
33.Edward is a student nurse. During his duty in the health center, she met Aling Isabella and
her family. Aling Isabella stated “Nilalagnat ako tuwing gabi at wala rin akong ganang
kumain.” Her statement is an example of what data?
a First level assessment
b Second level assessment
c Objective cue
d Subjective cue
34.After identifying the health problems, Edward proceeds to the second level assessment.
The product of second level assessment is?
a Objective and subjective cues
b Nursing diagnosis
c Formulation of goals
d Formulation of objectives
35.Data gathering method which is done through inspection, palpation, percussion,
auscultation, measurement of specific body parts and reviewing the body systems.
a Observation
b Record Review
c Interview
d Physical Examination
36.It refers to more specific statement of the desired result or outcomes of care:
a. objectives
b. evaluation
c. goal
d. skills
a. Assessment
b. Evaluation
c. Analysis
d. Nursing diagnosis
38. In taking care of a patient for surgery, the nurse noted that the patient manifested fear related to
surgery and its possible outcome. This statement is an example of:
a. Nursing diagnosis
b. Implementation
c. Assessment
d. Evaluation
42.This is to create a data base for problem identification: what type of assessment is it?
a) Emergency Assessment
b) Focus Assessment or On-going Assessment
c) Initial Assessment
d) Time-Lapsed Assessment
44.Occurs when patient responds to questioning. The most productive stage of an interview?
a) Body of the Interview
b) Opening Stage
c) Closing Stage
d) End stage
46.A deliberative, systematic phase that involves decision making and problem solving.
Formulating client goals with the patient. This is what phase?
a) Planning phase
b) Evaluation phase
c) Intervention phase
d) Assessment phase
47.Consists of doing and documenting the nursing care given to the patient. Carry out
planned activities to help the client. What step in the nursing process is this?
a) Implementing phase
b) Assessment phase
c) Evaluation phase
d) Planning phase
49.The main Purpose of the Evaluation Phase are the following except:
a) To determine client’s progress
b) To determine as to what extent the nursing goals have been met
c) To determine if the procedure is still needed
d) To determine the effectiveness of the care plan
50.All are requirements in doing implementing phase Except:
a) Adequate knowledge
b) Technical skills
c) Therapeutic use of self
d) Determine client’s progress