NURSING PROCESS REVIEW

Name: __________________________ Date: _____________

1. Which of the following group of terms best defines assessing in the nursing process?
A) problem focused, time lapsed, emergency based
B) design a plan of care, implement nursing interventions
C) collection, validation, communication of patient data---
D) nurse focused, establishing nursing goals

2. A nurse performing triage in an emergency room makes assessments of patients using

critical thinking skills. Which of the following are critical thinking activities linked to
assessment? Select all that apply.
A) carrying out a physician's order to intubate a patient
B) teaching a novice nurse the principles of triage
C) using the nursing process to diagnose a blocked airway---
D) interviewing a patient suspected of being a victim of abuse privately---
E) checking the data supplied by a patient with dementia with the family---
F) teaching a diabetic patient about the importance of proper foot care

3. Which of the following statements best describes the relationship between nursing
diagnosis and medical diagnosis?
A) The nursing diagnosis confirms the medical diagnosis.
B) The nursing diagnosis duplicates the medical diagnosis.
C) There is no relationship between nursing and medical diagnoses.
D) The nursing diagnosis is based on patient response to the medical diagnosis.---

4. Of the following information collected during a nursing assessment, which are

subjective data?
A) vomiting, pulse 96
B) respirations 22, blood pressure 130/80
C) nausea, abdominal pain---
D) pale skin, thick toenails

5. A nurse in the emergency department is completing an emergency assessment for a

teenager just admitted from a car crash. Which of the following is objective data?
A) “My leg hurts so bad. I can't stand it.”
B) “Appears anxious and frightened.”
C) “I am so sick; I am about to throw up.”
D) “Unable to palpate femoral pulse in left leg.”---
 6. Who or what is the primary source of information for a nursing history?
A) previous medical records
B) other healthcare personnel
C) the patient---
D) family members

7. Of the following data, what type would be collected during a physical assessment?
A) color, moisture, and temperature of the skin---
B) type, amount, and duration of pain
C) foods eaten that cause nausea
D) specific allergies resulting in itching

8. In addition to identifying responses to actual or potential health problems, what is

another purpose of the diagnosing step in the nursing process?
A) to collect information about subjective and objective data
B) to correlate nursing and medical diagnostic criteria
C) to identify etiologies of health problems---
D) to evaluate mutually developed expected outcomes

9. Which of the following patient care concerns is clearly a nursing responsibility?

A) prescribing medications
B) monitoring health status changes---
C) ordering diagnostic examinations
D) performing surgical procedures

10. After completing assessments, a nurse uses the data collected to identify appropriate
nursing diagnoses for a patient. What are the nursing diagnoses used for?
A) selecting nursing interventions to meet expected outcomes----
B) establishing a database of information for future comparison
C) mutually establishing desired outcomes of the plan of care
D) evaluating the effectiveness of the established plan of care

11. A nurse is reviewing the health history and physical assessment findings for a patient
who is having respiratory problems. Of the following data collected, what data from the
health history would be a cue to a nursing diagnosis for this problem?
A) “I often have diarrhea after I eat spicy foods.”
B) “My skin is so dry I just can't keep from scratching.”
C) “I get out of breath when I walk a few steps.”---
D) “I just feel so bad about myself these days.”
12. Of the following types of nursing diagnoses, which one is validated by the presence of
major defining characteristics?
A) risk nursing diagnosis
B) actual nursing diagnosis---
C) possible nursing diagnosis
D) wellness diagnosis

13. Which of the following nursing diagnoses is an example of a wellness diagnosis?

A) Acute Pain
B) Risk for Infection
C) Readiness for Enhanced Parenting---
D) Possible Chronic Low Self-Esteem

14. What is the primary purpose of the outcome identification and planning step of the
nursing process?
A) to collect and analyze data to establish a database
B) to interpret and analyze data to identify health problems
C) to write appropriate patient-centered nursing diagnoses
D) to design a plan of care for and with the patient---

15. A nurse is developing outcomes for a specific problem statement. What is one of the
most important considerations the nurse should have?
A) that the written outcomes are designed to meet nursing goals
B) to encourage the patient and family to be involved---
C) to discourage additions by other healthcare providers
D) why the nurse believes the outcome is important

16. What common problem is related to outcome identification and planning?

A) failing to involve the patient in the planning process---
B) collecting sufficient data to establish a database
C) stating specific and measurable outcomes based on nursing diagnoses
D) writing nursing orders that are clear and resolve the problem

17. What activity is carried out during the implementing step of the nursing process?
A) Assessments are made to identify human responses to health problems.
B) Mutual goals are established and desired patient outcomes are determined.
C) Planned nursing actions (interventions) are carried out.---
D) Desired outcomes are evaluated and, if necessary, the plan is modified.
18. A nurse is catheterizing a patient. What action illustrates respect for the patient's
privacy?
A) explaining the procedure to the family
B) leaving the patient's pajamas on
C) closing the door to the room---
D) asking another nurse if he wants to watch

19. A nurse delegates a specific intervention to a UAP. What implications does this have for
the nurse?
A) The UAP is responsible and accountable for his or her own actions.
B) Nurses do not have authority to delegate interventions.
C) The nurse transfers responsibility but is accountable for the outcome.---
D) The UAP can function in an independent role for all interventions.

20. According to the American Nurses Association, who determines the scope of nursing
practice?
A) Nurses---
B) lawyers
C) physicians
D) consumers

21. Which of the following best summarizes the evaluating step of the nursing process?
A) The nurse completes a health assessment to establish a database.
B) The patient and family have met healthcare goals and no longer need care.
C) The nurse and patient identify nursing diagnoses and appropriate interventions.
D) The nurse and patient measure achievement of planned outcomes of care. ----

22. What is the purpose of evaluation in the nursing process?

A) to direct future nursing interventions----
B) to formulate a database of nursing diagnoses
C) to complete an initial plan of care
D) to transfer medical orders to the plan of care