Chapter 12: Physical Assessment
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A patient with visual impairment is identified as at risk for falls related to blindness. An
appropriate intervention would be to:
a. assist the patient with feeding herself at the end of the meal.
b. arrange furnishings in room to provide clear pathways and orient the patient to
these.
c. take the patients blood pressure before she gets up in the morning.
d. report any falls immediately to the charge nurse and the doctor.
ANS: B
Providing clear pathways directly reduces the risk of patient falls.
DIF: Cognitive Level: Analysis REF: d 59 OBJ: Clinical Practice #6
TOP: Clinical Planning KEY: Nursing Process Step:
Planning MSC: NCLEX: Safe Effective Care Environment: safety and
infection control
2. The North American Nursing Diagnosis Association I (NANDA-I) list is revised and
updated every:
a. year.
b. 2 years.
c. 3 years.
d. 5 years.
ANS: B
NANDA-I meets every 2 years to revise and update the list.
DIF: Cognitive Level: Knowledge REF: d 61 OBJ: Theory #5
TOP: NANDA-I KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. A nursing care plan consists of:
a. nursing orders for individualized interventions to assist the patient to meet
expected outcomes.
b. orders for diagnostic and therapeutic procedures such as laboratory tests or
radiographs.
c. the physicians history and physical examination, as well as medical diagnoses.
d. laboratory and radiograph reports, pathology reports, and the medication record.
ANS: A
The nursing care plan consists of the nursing orders for interventions to address
problems and establish outcomes by which the plan can be evaluated.
DIF: Cognitive Level: Comprehension REF: d 65 OBJ: Clinical
Practice #5 TOP: Nursing Care Plan KEY: Nursing Process
Step: N/A MSC: NCLEX: N/A
4. In an acute care facility, a nursing care plan is usually reviewed and updated:
, a. every shift.
b. every 24 hours.
c. once every 3 days.
d. on admission and discharge.
ANS: B
Ongoing assessment, intervention, and evaluation lead to attainment or modification
of the original plan for the patient who is acutely ill. The nursing care plan must be
updated daily to reflect these changes.
DIF: Cognitive Level: Knowledge REF: d 65 OBJ: Clinical Practice #6
TOP: Nursing Care Plan KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
5. The nurse takes into consideration that the difference between a sign and a symptom is
that a sign is:
a. subjective data.
b. unreliable because it depends on translation.
c. can be verified by examination.
d. something a patient reports that is verified by a relative.
ANS: C
Signs are objective data that can be confirmed by examination, assessment, or
observation. Signs are reliable research-based data.
DIF: Cognitive Level: Comprehension REF: d 62 OBJ: Theory #2
TOP: Assessment (Data Collection) KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity:
basic care and comfort
6. The nurse clarifies that nursing orders are also called:
a. goals.
b. qualifiers.
c. interventions.
d. measurement criteria.
ANS: C
Nursing orders are also called nursing interventions and follow the same requirements
when placed in a nursing care plan.
DIF: Cognitive Level: Knowledge REF: d 65 OBJ: Theory #2
TOP: Nursing Orders KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
7. The nurse designs the goals for patients in long-term facilities to be:
a. conditional.
b. open ended.
c. based on behavioral norms.
d. long-term.
ANS: D
Long-term goals are more appropriate for patients in long-term facilities because they
will be there for an extended period and many of their health problems are chronic.
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A patient with visual impairment is identified as at risk for falls related to blindness. An
appropriate intervention would be to:
a. assist the patient with feeding herself at the end of the meal.
b. arrange furnishings in room to provide clear pathways and orient the patient to
these.
c. take the patients blood pressure before she gets up in the morning.
d. report any falls immediately to the charge nurse and the doctor.
ANS: B
Providing clear pathways directly reduces the risk of patient falls.
DIF: Cognitive Level: Analysis REF: d 59 OBJ: Clinical Practice #6
TOP: Clinical Planning KEY: Nursing Process Step:
Planning MSC: NCLEX: Safe Effective Care Environment: safety and
infection control
2. The North American Nursing Diagnosis Association I (NANDA-I) list is revised and
updated every:
a. year.
b. 2 years.
c. 3 years.
d. 5 years.
ANS: B
NANDA-I meets every 2 years to revise and update the list.
DIF: Cognitive Level: Knowledge REF: d 61 OBJ: Theory #5
TOP: NANDA-I KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. A nursing care plan consists of:
a. nursing orders for individualized interventions to assist the patient to meet
expected outcomes.
b. orders for diagnostic and therapeutic procedures such as laboratory tests or
radiographs.
c. the physicians history and physical examination, as well as medical diagnoses.
d. laboratory and radiograph reports, pathology reports, and the medication record.
ANS: A
The nursing care plan consists of the nursing orders for interventions to address
problems and establish outcomes by which the plan can be evaluated.
DIF: Cognitive Level: Comprehension REF: d 65 OBJ: Clinical
Practice #5 TOP: Nursing Care Plan KEY: Nursing Process
Step: N/A MSC: NCLEX: N/A
4. In an acute care facility, a nursing care plan is usually reviewed and updated:
, a. every shift.
b. every 24 hours.
c. once every 3 days.
d. on admission and discharge.
ANS: B
Ongoing assessment, intervention, and evaluation lead to attainment or modification
of the original plan for the patient who is acutely ill. The nursing care plan must be
updated daily to reflect these changes.
DIF: Cognitive Level: Knowledge REF: d 65 OBJ: Clinical Practice #6
TOP: Nursing Care Plan KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
5. The nurse takes into consideration that the difference between a sign and a symptom is
that a sign is:
a. subjective data.
b. unreliable because it depends on translation.
c. can be verified by examination.
d. something a patient reports that is verified by a relative.
ANS: C
Signs are objective data that can be confirmed by examination, assessment, or
observation. Signs are reliable research-based data.
DIF: Cognitive Level: Comprehension REF: d 62 OBJ: Theory #2
TOP: Assessment (Data Collection) KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity:
basic care and comfort
6. The nurse clarifies that nursing orders are also called:
a. goals.
b. qualifiers.
c. interventions.
d. measurement criteria.
ANS: C
Nursing orders are also called nursing interventions and follow the same requirements
when placed in a nursing care plan.
DIF: Cognitive Level: Knowledge REF: d 65 OBJ: Theory #2
TOP: Nursing Orders KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
7. The nurse designs the goals for patients in long-term facilities to be:
a. conditional.
b. open ended.
c. based on behavioral norms.
d. long-term.
ANS: D
Long-term goals are more appropriate for patients in long-term facilities because they
will be there for an extended period and many of their health problems are chronic.
