C HAPTER 05: A SSESSMENT , N URSING
D IAGNOSIS , AND P LANNING
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. A patient with visual impairment is identified as at -risk for falls related to
blindness. An appropriate intervention would be:
a. assist the patient with feeding herself at the end of the meal.
b. arrange furnishings in room to provide c lear pathways and orient the
patient to these.
c. take the patient’s blood pressure before she gets up in the morning.
d. report any falls immediatel y to the charge nurse and the doctor.
ANS: B
Providing clear pathways directl y reduces the risk of patient falls.
DIF: Cognitive Level: Anal ysis REF: p.62 OBJ: Clinical
Practice #6 TOP: Clinical Planning KEY: Nursing Process
Step: Planning MSC: NCLEX: Safe, Effective Care
Environment: Safet y 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: p. 65 OBJ:
Theory #5 TOP: NANDA I KEY: Nursing Proc ess 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 health care provider’s 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: p. 69
OBJ: Clinical Practice #5 TOP: Nursing Care
Plan KEY: Nursing Process Step: Planning MSC: NCLEX:
N/A
4. In an acute care faci lit y, a nursing care plan is usuall y 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 acutel y ill. The
nursing care plan must be updated every day to reflect these changes.
DIF: Cognitive Level: Knowledge REF: p. 69 OBJ:
Clinical Practice #6 TOP: Nursing Care Plan KEY: Nursing
Process Step: Planning MSC: NCLEX: N/A
5. The nurse takes into consideration that the difference between a sign and a
s ymptom 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 relati ve.
ANS: C
D IAGNOSIS , AND P LANNING
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. A patient with visual impairment is identified as at -risk for falls related to
blindness. An appropriate intervention would be:
a. assist the patient with feeding herself at the end of the meal.
b. arrange furnishings in room to provide c lear pathways and orient the
patient to these.
c. take the patient’s blood pressure before she gets up in the morning.
d. report any falls immediatel y to the charge nurse and the doctor.
ANS: B
Providing clear pathways directl y reduces the risk of patient falls.
DIF: Cognitive Level: Anal ysis REF: p.62 OBJ: Clinical
Practice #6 TOP: Clinical Planning KEY: Nursing Process
Step: Planning MSC: NCLEX: Safe, Effective Care
Environment: Safet y 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: p. 65 OBJ:
Theory #5 TOP: NANDA I KEY: Nursing Proc ess 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 health care provider’s 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: p. 69
OBJ: Clinical Practice #5 TOP: Nursing Care
Plan KEY: Nursing Process Step: Planning MSC: NCLEX:
N/A
4. In an acute care faci lit y, a nursing care plan is usuall y 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 acutel y ill. The
nursing care plan must be updated every day to reflect these changes.
DIF: Cognitive Level: Knowledge REF: p. 69 OBJ:
Clinical Practice #6 TOP: Nursing Care Plan KEY: Nursing
Process Step: Planning MSC: NCLEX: N/A
5. The nurse takes into consideration that the difference between a sign and a
s ymptom 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 relati ve.
ANS: C
