CHAPTER 5: Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford

Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford Chapter 5: Introduction to the Nursing Process Multiple Choice Questions 1. The nurse identifies the nursing process as the foundation of professional nursing practice and can define it in which appropriate terms? A. The framework that nurses use to provide care. B. A complex process during which nurses think about their thinking. C. The process that allows nurses to collect essential data. D. Thinking like a nurse in developing plans of care. Answer: A Explanation: The nursing process is the framework within which nurses provide organized and effective patient care. It ensures systematic delivery of care through assessment, diagnosis, planning, implementation, and evaluation. Why Other Options Are Wrong: B describes critical thinking, not the nursing process. C focuses only on data collection, which is one step of the process. D refers to critical thinking in care planning, not the overarching framework. 2. The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The nurse knows which essential step was added in 1991? A. Assessment B. Diagnosis C. Outcome identification D. Evaluation Answer: C Explanation: Outcome identification was added in 1991 as part of the planning step, enhancing the process by specifying measurable goals for patient care. Why Other Options Are Wrong: A, B, and D were part of the original five steps and not additions in 1991. 3. Since the nursing process is cyclic rather than linear, the nurse knows that as an individual patient's condition changes the nurse should anticipate what concept? A. The nurse's thought processes do not have to vary. B. Plans of care are easier to use and do not need modification. C. The accuracy and effectiveness of thought processes must be considered. D. Reflective thought is not necessary since issues tend to be repetitive. Answer: C Explanation: The cyclic nature requires nurses to continually evaluate and adjust thought processes and care plans based on changing patient needs. Why Other Options Are Wrong: A contradicts adaptability. B ignores the need for modifications. D overlooks the necessity of reflective thought in dynamic care. 4. The charge nurse is discussing a patient's care plan during a team meeting. The team determines that the patient has not met the goal of "ambulating to the nurse's station twice a day" and decides to revise the plan. The nurse recognizes which characteristic of the nursing process most represents this decision? A. Organization B. Dynamics C. Adaptability D. Outcome orientation Answer: D Explanation: Revising the plan to meet unmet goals demonstrates a focus on achieving specific patient outcomes. Why Other Options Are Wrong: A refers to structure, not outcome focus. B and C describe process flexibility but not the goal-directed nature. 5. The nurse is caring for a patient who will be discharged home following surgical repair of a broken shoulder. The patient tells the nurse, "I don't have anyone at home who can help me cook my meals. Is there something you can do?" When demonstrating the adaptability of the nursing process, the nurse should carry out which task? A. Adjust the patient's care plan so that nursing goals can be met. B. Consult the care provider about extending the patient's hospitalization. C. Abandon the plan of care as not able to be done. D. Contact the social worker about community services. Answer: D Explanation: Adaptability involves modifying care to address patient needs, such as arranging community support for meal preparation. Why Other Options Are Wrong: A focuses on nurse goals, not patient needs. B is impractical for long-term care. C neglects problem-solving. 6. The community health nurse is applying the nursing process to the care of patients with coronary artery disease. The nurse determines that most of the patients eat high-fat meals from local fast-food restaurants and plans a nutrition workshop. The nurse is applying which characteristic of the nursing process? A. Organization B. Dynamics C. Adaptability D. Collaboration Answer: C Explanation: Adapting interventions (e.g., a workshop) to address population-specific needs (high-fat diets) exemplifies adaptability. Why Other Options Are Wrong: A refers to systematic structure, not tailored interventions. B and D describe process traits but not the specific adjustment made. 7. The nursing student is caring for a patient admitted with severe anemia. The patient receives two units of packed red blood cells and tells the student, "I am feeling so much better. I'm not so tired anymore and can bathe myself." The student reviews the patient goal "report an increase in activity tolerance" and concludes that the patient's goal has been met and adjusts the patient's plan of care. The nurse knows this is applying which characteristic of the nursing process? A. Organization B. Dynamics C. Adaptability D. Collaboration Answer: B Explanation: Adjusting the care plan based on achieved goals reflects the dynamic nature of the nursing process. Why Other Options Are Wrong: A refers to structure, not responsiveness. C and D describe other process traits unrelated to goal evaluation. 8. The nurse is completing the health history on a patient admitted for cardiac rehabilitation. The nurse recognizes that the health history is conducted in which step of the nursing process? A. Assessment B. Diagnosis C. Implementation D. Evaluation Answer: A Explanation: Health history is part of data collection during the assessment phase. Why Other Options Are Wrong: B involves analyzing data, C is intervention, and D evaluates outcomes. 9. The nurse is assisting a patient to bed when the patient says, "My chest hurts and my left arm feels numb. What's wrong with me?" What is the type and source of data obtained from the patient's complaint? A. Objective data from a primary source B. Objective data from a secondary source C. Subjective data from a primary source D. Subjective data from a secondary source Answer: C Explanation: The patient's verbal report is subjective (symptoms) and obtained directly (primary source). Why Other Options Are Wrong: A and B involve observable signs. D would involve indirect reports from others. 10. The nurse identifies which statement to be a correctly written Nursing diagnosis appropriate for a patient's plan of care? A. Ineffective airway clearance related to excessive secretions as evidenced by diminished breath sounds. B. Imbalanced nutrition: less than body requirements. C. Impaired physical mobility related to contractures. D. Risk for suffocation related to smoking in bed as evidenced by absent breath sounds. Answer: A Explanation: It includes all required components: problem, etiology, and evidence (signs/symptoms). Why Other Options Are Wrong: B lacks etiology and evidence. C omits evidence. D incorrectly includes evidence for a risk diagnosis. 11. The nurse is admitting a patient experiencing chest discomfort and shortness of breath, who has a history of stroke. When the nurse documents the Nursing diagnosis "Risk for impaired mobility related to history of stroke," the nurse knows which condition to be the risk factor? A. Stroke B. History of stroke C. Chest discomfort D. Shortness of breath Answer: B Explanation: Risk factors are conditions increasing vulnerability (e.g., history of stroke). Why Other Options Are Wrong: A is the potential problem, not the risk factor. C and D are current symptoms. 12. A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation Answer: A Explanation: Observing and gathering data (shortness of breath, restlessness) occurs during assessment. Why Other Options Are Wrong: B involves goal-setting, C is intervention, and D evaluates outcomes. 13. While the nurse is assisting with morning care, the patient has a tonic clonic seizure. The nurse immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation Answer: C Explanation: Turning the patient is an immediate intervention (implementation). Why Other Options Are Wrong: A involves data collection, B is planning, and D assesses outcomes. 14. The nurse is caring for a patient diagnosed with Lyme disease. The patient tells the nurse, "My heart seems to be skipping some beats. My doctor told me to let the nurse know if this happens since it might be a complication of my disease." The nurse auscultates the heart and confirms the palpitations. Which step of the nursing process does the nurse's action demonstrate? A. Assessment B. Planning C. Implementation D. Evaluation Answer: A Explanation: Auscultation and data confirmation are part of assessment. Why Other Options Are Wrong: B, C, and D involve later steps of the process. 15. In which step of the nursing process does the nurse prioritize the Nursing diagnoses and identify interventions to address the patient goals? A. Assessment B. Planning C. Implementation D. Evaluation Answer: B Explanation: Planning involves prioritizing diagnoses and setting interventions/goals. Why Other Options Are Wrong: A gathers data, C executes interventions, and D evaluates results. 16. The nurse writes a short-term goal for a patient scheduled for surgery in the morning and identifies which goal that contains all the necessary elements? A. The patient will walk to the bathroom within 48 hours after surgery. B. The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery. C. The patient will walk to the bathroom without experiencing shortness of breath. D. The patient will walk to the bathroom without experiencing shortness of breath after surgery. Answer: B Explanation: It includes all elements: patient-focused action, measurable outcome, and timeframe. Why Other Options Are Wrong: A omits the outcome (shortness of breath). C and D lack a timeframe. 17. A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. When the nurse asks the manager if there is a document written by the physician for this type of reaction, the nurse is referring to which concept? A. Protocol B. Clinical pathway C. Standing order D. Care map Answer: C Explanation: Standing orders are physician-prepared directives for specific clinical situations. Why Other Options Are Wrong: A and B are broader guidelines. D is synonymous with clinical pathways. 18. All nursing interventions that are implemented for patients must be documented or charted. The nurse knows that proper documentation of interventions leads to what positive outcome? A. Proper documentation facilitates communication with all members of the health care team. B. Proper documentation is only considered "legal" if documented in the paper chart. C. Proper documentation prevents errors of omission and repetition of care. D. Proper documentation does not directly measure goal achievement or outcomes. Answer: A Explanation: Documentation ensures clear communication among team members and legal accountability. Why Other Options Are Wrong: B is outdated (electronic records are legal). C overstates prevention (reduces but doesn’t eliminate errors). D is incorrect as documentation aids outcome evaluation. 19. The nurse makes the following entry on the patient's care plan: "Goal not met. Patient refuses to walk and states, 'I'm afraid of falling.'" The nurse should complete which next action? A. Ignore the patient's concern in evaluating goal attainment. B. Document the patient's unwillingness to continue the plan of care. C. Continue the plan of care as originally agreed upon. D. Modify the care plan in response to the patient's condition and wishes. Answer: D Explanation: Modifying the plan addresses the patient's fear and ensures individualized care. Why Other Options Are Wrong: A and B are non-therapeutic. C disregards the patient's expressed need. 20. The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a patient scheduled for back surgery. Which step of the nursing process is the nurse addressing? A. Assessment B. Diagnosis C. Implementation D. Evaluation Answer: C Explanation: Teaching interventions are part of implementation. Why Other Options Are Wrong: A, B, and D involve other phases of the nursing process. 21. The nurse develops a list of Nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, "I understand that I will lose most of my hair. Will it grow back?" The nurse identifies which diagnosis will have the highest priority? A. Disturbed body image B. Nausea C. Risk for bleeding D. Imbalanced nutrition: less than body requirements Answer: A Explanation: The patient's concern about hair loss (body image) is the immediate psychosocial priority. Why Other Options Are Wrong: B, C, and D are potential physiological issues but secondary to the patient's expressed distress. 22. The nurse is gathering data on a patient with acute bacterial pneumonia. The nurse recognizes that this is an example of which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation Answer: A Explanation: Data collection (e.g., symptoms of pneumonia) occurs during assessment. Why Other Options Are Wrong: B, C, and D involve subsequent steps in the process. MULTIPLE RESPONSE QUESTIONS 1. The nurse knows which statements would be considered objective data? (Select all that apply.) A. "I'm short of breath." B. "Blood pressure 90/68, apical pulse 102, skin pale and moist." C. "Lung sounds clear bilaterally, diminished in right lower lobe." D. "I feel weak all over when I exert myself." E. "My pain level is down to 2. It was 8." Answer: B, C Explanation: Objective data are measurable or observable (e.g., vital signs, physical exam findings). Why Other Options Are Wrong: A, D, and E are subjective (patient-reported symptoms). 2. The nurse is attempting to develop Nursing diagnoses for a patient. The nurse understands that Nursing diagnoses have which characteristics? (Select all that apply.) A. Nursing diagnoses identify actual or potential problems as well as responses to a problem. B. Nursing diagnoses require naming patient problems using Nursing diagnostic labels. C. Nursing diagnoses utilize objective data since subjective data are often inaccurate. D. Nursing diagnoses include unvalidated data to determine an accurate and thorough diagnosis. E. Nursing diagnoses are similar to medical diagnoses since they both are labels for diseases. Answer: A, B Explanation: Nursing diagnoses describe patient problems/responses and use standardized labels (NANDA-I). Why Other Options Are Wrong: C is incorrect because subjective data are validated and used. D contradicts the need for validated data. E confuses Nursing diagnoses (responses) with medical diagnoses (diseases). 3. The nurse recognizes that establishing short- and long-term goals to address Nursing diagnoses involve which actions? (Select all that apply.) A. Discussion with the patient B. Exclusion of family with making patient decisions C. Collaboration with other members of health care team D. Making the health care provider as the central figure E. Coordination of care as collaborative care Answer: A, C, E Explanation: Goal-setting involves patient input, teamwork, and collaborative care coordination. Why Other Options Are Wrong: B excludes family involvement, which is often critical. D misplaces the nurse's central role in care coordination.