ACC NURSING 140
H
MIDTERM | Questions and
Answers | Complete Solution |
HACC Nursing Exam Prep | A+
Graded | Pass Guaranteed
[HACC NURSING 140 MIDTERM]
[QUESTIONS AND ANSWERS WI
**[DOMAIN 1: NURSING PROCESS & CRITICAL THINKING 25 QUESTIONS]**
* *1. What are the five phases of the nursing process in correct order?**
- A) Planning, Assessment, Implementation, Diagnosis, Evaluation
- B) Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE) **[CORRECT]**
- C) Diagnosis, Assessment, Planning, Evaluation, Implementation
- D) Implementation, Assessment, Diagnosis, Planning, Evaluation
* *Rationale:** The nursing process follows the acronym ADPIE: Assessment (collecting data),
Diagnosis (analyzing data to identify problems), Planning (setting goals and interventions),
Implementation (carrying out interventions), and Evaluation (measuring progress toward goals).
This systematic approach ensures comprehensive, individualized patient care.
* *2. During which phase of the nursing process does the nurse collect subjective and objective
data?**
- A) Diagnosis
- B) Assessment **[CORRECT]**
- C) Planning
- D) Evaluation
* *Rationale:** The Assessment phase involves systematic collection of all relevant patient data.
Subjective data includes the patient's verbal descriptions, feelings, and perceptions (symptoms).
Objective data includes observable, measurable information collected through physical
, xamination, vital signs, and diagnostic tests (signs). Thorough assessment is the foundation for
e
all subsequent nursing process steps.
* *3. During which phase of the nursing process does the nurse analyze data to identify client
problems?**
- A) Assessment
- B) Diagnosis **[CORRECT]**
- C) Implementation
- D) Evaluation
* *Rationale:** The Diagnosis phase involves analyzing assessment data to identify actual or
potential health problems. Nurses use clinical judgment to formulate nursing diagnoses using
standardized terminology (NANDA-I). This phase bridges assessment data to planned
interventions by clearly defining what needs to be addressed.
* *4. During which phase of the nursing process does the nurse set goals and develop
interventions?**
- A) Assessment
- B) Diagnosis
- C) Planning **[CORRECT]**
- D) Implementation
* *Rationale:** The Planning phase involves establishing measurable, achievable goals and
expected outcomes, then developing specific nursing interventions to achieve those goals.
Planning includes prioritizing problems, setting timelines, and individualizing care based on
patient needs, preferences, and evidence-based practice.
* *5. During which phase of the nursing process does the nurse carry out nursing
interventions?**
- A) Planning
- B) Implementation **[CORRECT]**
- C) Evaluation
- D) Assessment
* *Rationale:** The Implementation phase involves actually performing the planned nursing
interventions. This includes direct care activities (medication administration, wound care, patient
education) and indirect care (documentation, care coordination). Implementation requires
clinical skills, critical thinking, and adaptation to changing patient conditions.
* *6. During which phase of the nursing process does the nurse measure client progress toward
goals?**
- A) Implementation
- B) Evaluation **[CORRECT]**
- C) Planning
,- D) Diagnosis
* *Rationale:** The Evaluation phase involves comparing actual patient outcomes to the
expected outcomes established during planning. The nurse determines whether goals were
met, partially met, or not met, and uses this information to continue, modify, or terminate the
care plan. Evaluation completes the cycle and may lead back to reassessment.
* *7. What is subjective data in nursing assessment?**
- A) Vital signs measured by the nurse
- B) Client's verbal descriptions, feelings, and perceptions (symptoms) **[CORRECT]**
- C) Laboratory test results
- D) Physical examination findings
* *Rationale:** Subjective data consists of information that only the patient can provide—their
personal experiences, feelings, perceptions, and descriptions of symptoms. Examples include "I
feel nauseous," "My pain is 7/10," or "I'm worried about my surgery." This data cannot be
directly observed or measured by others.
* *8. What is objective data in nursing assessment?**
- A) Patient's description of pain
- B) Observable, measurable data collected by the nurse (signs) **[CORRECT]**
- C) Patient's feelings about illness
- D) Patient's health history
* *Rationale:** Objective data consists of observable, measurable information that can be
verified by multiple healthcare providers. This includes vital signs, physical examination findings
(rashes, edema, wounds), laboratory values, and diagnostic test results. Objective data
provides concrete evidence of patient condition.
* *9. Who is considered the primary source of patient data?**
- A) Family members
- B) The client **[CORRECT]**
- C) Medical records
- D) Other healthcare providers
* *Rationale:** The patient is always the primary source of data because they have direct
knowledge of their symptoms, experiences, and health history. Information obtained directly
from the patient is generally most accurate and should be prioritized when there are
discrepancies with secondary sources.
* *10. Which of the following is a secondary source of patient data?**
- A) The patient describing their pain
- B) Family members providing health history **[CORRECT]**
- C) Patient's self-report of symptoms
, - D) Patient's description of feelings
* *Rationale:** Secondary sources include anyone or anything other than the patient
themselves—family members, friends, other healthcare providers, medical records, and
literature. Secondary sources are valuable when the patient cannot provide information
(unconscious, confused, pediatric) but should be verified when possible.
* *11. What is an actual nursing diagnosis?**
- A) A problem the client is vulnerable to developing
- B) A client problem present at the time of assessment **[CORRECT]**
- C) A medical diagnosis made by a physician
- D) A laboratory value outside normal range
* *Rationale:** An actual nursing diagnosis describes a health problem that currently exists
based on assessment data. It requires defining characteristics (signs and symptoms) that are
present and measurable. Example: "Impaired Gas Exchange related to alveolar-capillary
membrane changes as evidenced by SpO2 88%, dyspnea, and crackles."
* *12. What is a risk nursing diagnosis?**
- A) A problem that currently exists
- B) A client vulnerability to developing a problem **[CORRECT]**
- C) A medical condition
- D) A normal finding
* *Rationale:** A risk nursing diagnosis describes a situation where the patient is vulnerable to
developing a negative health condition but does not currently have the problem. It requires risk
factors that increase susceptibility. Example: "Risk for Falls related to unsteady gait and use of
antihypertensive medications." No defining characteristics are present yet.
* *13. What is a health promotion nursing diagnosis?**
- A) A disease process
- B) A client's motivation and desire to improve their health status **[CORRECT]**
- C) A medical emergency
- D) A chronic illness
* *Rationale:** A health promotion nursing diagnosis describes a patient's readiness and
motivation to improve their health behaviors or achieve a higher level of wellness. It focuses on
enhancing well-being rather than treating illness. Example: "Readiness for Enhanced Nutrition"
or "Readiness for Enhanced Sleep."
* *14. What are the three components of a nursing diagnosis statement?**
- A) Medical diagnosis, treatment, prognosis
- B) NANDA-I label, related factors (related to...), defining characteristics (as evidenced by...)
**[CORRECT]**
H
MIDTERM | Questions and
Answers | Complete Solution |
HACC Nursing Exam Prep | A+
Graded | Pass Guaranteed
[HACC NURSING 140 MIDTERM]
[QUESTIONS AND ANSWERS WI
**[DOMAIN 1: NURSING PROCESS & CRITICAL THINKING 25 QUESTIONS]**
* *1. What are the five phases of the nursing process in correct order?**
- A) Planning, Assessment, Implementation, Diagnosis, Evaluation
- B) Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE) **[CORRECT]**
- C) Diagnosis, Assessment, Planning, Evaluation, Implementation
- D) Implementation, Assessment, Diagnosis, Planning, Evaluation
* *Rationale:** The nursing process follows the acronym ADPIE: Assessment (collecting data),
Diagnosis (analyzing data to identify problems), Planning (setting goals and interventions),
Implementation (carrying out interventions), and Evaluation (measuring progress toward goals).
This systematic approach ensures comprehensive, individualized patient care.
* *2. During which phase of the nursing process does the nurse collect subjective and objective
data?**
- A) Diagnosis
- B) Assessment **[CORRECT]**
- C) Planning
- D) Evaluation
* *Rationale:** The Assessment phase involves systematic collection of all relevant patient data.
Subjective data includes the patient's verbal descriptions, feelings, and perceptions (symptoms).
Objective data includes observable, measurable information collected through physical
, xamination, vital signs, and diagnostic tests (signs). Thorough assessment is the foundation for
e
all subsequent nursing process steps.
* *3. During which phase of the nursing process does the nurse analyze data to identify client
problems?**
- A) Assessment
- B) Diagnosis **[CORRECT]**
- C) Implementation
- D) Evaluation
* *Rationale:** The Diagnosis phase involves analyzing assessment data to identify actual or
potential health problems. Nurses use clinical judgment to formulate nursing diagnoses using
standardized terminology (NANDA-I). This phase bridges assessment data to planned
interventions by clearly defining what needs to be addressed.
* *4. During which phase of the nursing process does the nurse set goals and develop
interventions?**
- A) Assessment
- B) Diagnosis
- C) Planning **[CORRECT]**
- D) Implementation
* *Rationale:** The Planning phase involves establishing measurable, achievable goals and
expected outcomes, then developing specific nursing interventions to achieve those goals.
Planning includes prioritizing problems, setting timelines, and individualizing care based on
patient needs, preferences, and evidence-based practice.
* *5. During which phase of the nursing process does the nurse carry out nursing
interventions?**
- A) Planning
- B) Implementation **[CORRECT]**
- C) Evaluation
- D) Assessment
* *Rationale:** The Implementation phase involves actually performing the planned nursing
interventions. This includes direct care activities (medication administration, wound care, patient
education) and indirect care (documentation, care coordination). Implementation requires
clinical skills, critical thinking, and adaptation to changing patient conditions.
* *6. During which phase of the nursing process does the nurse measure client progress toward
goals?**
- A) Implementation
- B) Evaluation **[CORRECT]**
- C) Planning
,- D) Diagnosis
* *Rationale:** The Evaluation phase involves comparing actual patient outcomes to the
expected outcomes established during planning. The nurse determines whether goals were
met, partially met, or not met, and uses this information to continue, modify, or terminate the
care plan. Evaluation completes the cycle and may lead back to reassessment.
* *7. What is subjective data in nursing assessment?**
- A) Vital signs measured by the nurse
- B) Client's verbal descriptions, feelings, and perceptions (symptoms) **[CORRECT]**
- C) Laboratory test results
- D) Physical examination findings
* *Rationale:** Subjective data consists of information that only the patient can provide—their
personal experiences, feelings, perceptions, and descriptions of symptoms. Examples include "I
feel nauseous," "My pain is 7/10," or "I'm worried about my surgery." This data cannot be
directly observed or measured by others.
* *8. What is objective data in nursing assessment?**
- A) Patient's description of pain
- B) Observable, measurable data collected by the nurse (signs) **[CORRECT]**
- C) Patient's feelings about illness
- D) Patient's health history
* *Rationale:** Objective data consists of observable, measurable information that can be
verified by multiple healthcare providers. This includes vital signs, physical examination findings
(rashes, edema, wounds), laboratory values, and diagnostic test results. Objective data
provides concrete evidence of patient condition.
* *9. Who is considered the primary source of patient data?**
- A) Family members
- B) The client **[CORRECT]**
- C) Medical records
- D) Other healthcare providers
* *Rationale:** The patient is always the primary source of data because they have direct
knowledge of their symptoms, experiences, and health history. Information obtained directly
from the patient is generally most accurate and should be prioritized when there are
discrepancies with secondary sources.
* *10. Which of the following is a secondary source of patient data?**
- A) The patient describing their pain
- B) Family members providing health history **[CORRECT]**
- C) Patient's self-report of symptoms
, - D) Patient's description of feelings
* *Rationale:** Secondary sources include anyone or anything other than the patient
themselves—family members, friends, other healthcare providers, medical records, and
literature. Secondary sources are valuable when the patient cannot provide information
(unconscious, confused, pediatric) but should be verified when possible.
* *11. What is an actual nursing diagnosis?**
- A) A problem the client is vulnerable to developing
- B) A client problem present at the time of assessment **[CORRECT]**
- C) A medical diagnosis made by a physician
- D) A laboratory value outside normal range
* *Rationale:** An actual nursing diagnosis describes a health problem that currently exists
based on assessment data. It requires defining characteristics (signs and symptoms) that are
present and measurable. Example: "Impaired Gas Exchange related to alveolar-capillary
membrane changes as evidenced by SpO2 88%, dyspnea, and crackles."
* *12. What is a risk nursing diagnosis?**
- A) A problem that currently exists
- B) A client vulnerability to developing a problem **[CORRECT]**
- C) A medical condition
- D) A normal finding
* *Rationale:** A risk nursing diagnosis describes a situation where the patient is vulnerable to
developing a negative health condition but does not currently have the problem. It requires risk
factors that increase susceptibility. Example: "Risk for Falls related to unsteady gait and use of
antihypertensive medications." No defining characteristics are present yet.
* *13. What is a health promotion nursing diagnosis?**
- A) A disease process
- B) A client's motivation and desire to improve their health status **[CORRECT]**
- C) A medical emergency
- D) A chronic illness
* *Rationale:** A health promotion nursing diagnosis describes a patient's readiness and
motivation to improve their health behaviors or achieve a higher level of wellness. It focuses on
enhancing well-being rather than treating illness. Example: "Readiness for Enhanced Nutrition"
or "Readiness for Enhanced Sleep."
* *14. What are the three components of a nursing diagnosis statement?**
- A) Medical diagnosis, treatment, prognosis
- B) NANDA-I label, related factors (related to...), defining characteristics (as evidenced by...)
**[CORRECT]**
