,Chapter .1: .Professional .Nursing .Practice
MULTIPLE .CHOICE
1. The .nurse .completes .an .admission .database .and .explains .that .the .plan .of
.care .and .discharge .goals .will .be .developed .with .the .patient’s .input. .The .patient .states,
.“How .is .this .different .from .what .the .doctor .does?” .Which .response .would .be .most
.appropriate .for .the .nurse .to .make?
a. “The .role .of .the .nurse .is .to .administer .medications .and .other .treatments .prescribed
by .your .doctor.”
b. “The .nurse’s .job .is .to .help .the .doctor .by .collecting .information .and
.communicating
any .problems .that .occur.”
c. “Nurses .perform .many .of .the .same .procedures .as .the .doctor, .but .nurses .are .with
.the
patients .for .a .longer .time .than .the .doctor.”
d. “In .addition .to .caring .for .you .while .you .are .sick, .the .nurses .will .assist .you .to
develop .an .individualized .plan .to .maintain .your .health.”
ANS: . D
This .response .is .consistent .with .the .American .Nurses .Association .(ANA) .definition .of
.nursing, .which .describes .the .role .of .nurses .in .promoting .health. .The .other .responses
.describe .some .of .the .dependent .and .collaborative .functions .of .the .nursing .role .but .do .not
.accurately .describe .the .nurse’s .role .in .the .health .care .system.
2. The .nurse .describes .to .a .student .nurse .how .to .use .evidence-based .practice
.guidelines .when .caring .for .patients. .Which .statement, .if .made .by .the .nurse, .would .be .the
.most .accurate?
a. “Inferences .from .clinical .research .studies .are .used .as .a .guide.”
b. “Patient .care .is .based .on .clinical .judgment, .experience, .and .traditions.”
c. “Data .are .evaluated .to .show .that .the .patient .outcomes .are .consistently .met.”
d. “Recommendations .are .based .on .research, .clinical .expertise, .and .patient .prefer-
ences.”
ANS: . D
Evidence-based .practice .(EBP) .is .the .use .of .the .best .research-based .evidence .combined
.with .clinician .expertise. .Clinical .judgment .based .on .the .nurse’s .clinical .experience .is .part
.of .EBP, .but .clinical .decision .making .should .also .incorporate .current .research .and
.research-based .guidelines. .Evaluation .of .patient .outcomes .is .important, .but .interventions
.should .be .based .on .research .from .randomized .control .studies .with .a .large .number .of
.subjects.
3. The .nurse .teaches .a .student .nurse .about .how .to .apply .the .nursing .process
.when .providing .patient .care. .Which .statement, .if .made .by .the .student .nurse, .indicates .that
.teaching
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,was .successful?
a. “The .nursing .process .is .a .scientific-based .method .of .diagnosing .the .patient’s
.health
care .problems.”
b. “The .nursing .process .is .a .problem-solving .tool .used .to .identify .and .treat .patients’
health .care .needs.”
c. “The .nursing .process .is .based .on .nursing .theory .that .incorporates .the .biopsychoso-
cial .nature .of .humans.”
d. “The .nursing .process .is .used .primarily .to .explain .nursing .interventions .to .other
health .care .professionals.”
ANS: . B
The .nursing .process .is .a .problem-solving .approach .to .the .identification .and .treatment .of
.patients’ .problems. .Diagnosis .is .only .one .phase .of .the .nursing .process. .The .primary .use .of
.the .nursing .process .is .in .patient .care, .not .to .establish .nursing .theory .or .explain .nursing
.interven- .tions .to .other .health .care .professionals.
4. A .patient .has .been .admitted .to .the .hospital .for .surgery .and .tells .the .nurse, .“I
.do .not .feel .comfortable .leaving .my .children .with .my .parents.” .Which .action .should .the
.nurse .take .next?
a. Reassure .the .patient .that .these .feelings .are .common .for .parents.
b. Have .the .patient .call .the .children .to .ensure .that .they .are .doing .well.
c. Gather .more .data .about .the .patient’s .feelings .about .the .child-care .arrangements.
d. Call .the .patient’s .parents .to .determine .whether .adequate .child .care .is .being .provid-
ed.
ANS: . C
Since .a .complete .assessment .is .necessary .in .order .to .identify .a .problem .and .choose .an
.appropriate .intervention, .the .nurse’s .first .action .should .be .to .obtain .more .information. .The
.other .actions .may .be .appropriate, .but .more .assessment .is .needed .before .the .best
.intervention .can .be .chosen.
5. A .patient .who .is .paralyzed .on .the .left .side .of .the .body .after .a .stroke
.develops .a .pressure .ulcer .on .the .left .hip. .Which .nursing .diagnosis .is .most .appropriate?
a. Impaired .physical .mobility .related .to .left-sided .paralysis
b. Risk .for .impaired .tissue .integrity .related .to .left-sided .weakness
c. Impaired .skin .integrity .related .to .altered .circulation .and .pressure
d. Ineffective .tissue .perfusion .related .to .inability .to .move .independently
ANS: . C
The .patient’s .major .problem .is .the .impaired .skin .integrity .as .demonstrated .by .the .presence
.of .a .pressure .ulcer. .The .nurse .is .able .to .treat .the .cause .of .altered .circulation .and .pressure
.by .frequently .repositioning .the .patient. .Although .left-sided .weakness .is .a .problem .for .the
.patient,
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, the .nurse .cannot .treat .the .weakness. .The .“risk .for” .diagnosis .is .not .appropriate .for .this
.patient, .who .already .has .impaired .tissue .integrity. .The .patient .does .have .ineffective .tissue
.perfusion, .but .the .impaired .skin .integrity .diagnosis .indicates .more .clearly .what .the .health
.problem .is.
6. A .patient .with .a .bacterial .infection .has .a .nursing .diagnosis .of .deficient
.fluid .volume .related .to .excessive .diaphoresis. .Which .outcome .would .the .nurse .recognize
.as .most .appropriate .for .this .patient?
a. Patient .has .a .balanced .intake .and .output.
b. Patient’s .bedding .is .changed .when .it .becomes .damp.
c. Patient .understands .the .need .for .increased .fluid .intake.
d. Patient’s .skin .remains .cool .and .dry .throughout .hospitalization.
ANS: . A
This .statement .gives .measurable .data .showing .resolution .of .the .problem .of .deficient .fluid
.volume .that .was .identified .in .the .nursing .diagnosis .statement. .The .other .statements .would
.not .indicate .that .the .problem .of .deficient .fluid .volume .was .resolved.
7. A .nurse .asks .the .patient .if .pain .was .relieved .after .receiving .medication.
.What .is .the .purpose .of .the .evaluation .phase .of .the .nursing .process?
a. To .determine .if .interventions .have .been .effective .in .meeting .patient .outcomes
b. To .document .the .nursing .care .plan .in .the .progress .notes .of .the .medical .record
c. To .decide .whether .the .patient’s .health .problems .have .been .completely .resolved
d. To .establish .if .the .patient .agrees .that .the .nursing .care .provided .was .satisfactory
ANS: . A
Evaluation .consists .of .determining .whether .the .desired .patient .outcomes .have .been .met
.and .whether .the .nursing .interventions .were .appropriate. .The .other .responses .do .not
.describe .the .evaluation .phase.
8. The .nurse .interviews .a .patient .while .completing .the .health .history .and
.physical .examination. .What .is .the .purpose .of .the .assessment .phase .of .the .nursing .process?
a. To .teach .interventions .that .relieve .health .problems
b. To .use .patient .data .to .evaluate .patient .care .outcomes
c. To .obtain .data .with .which .to .diagnose .patient .problems
d. To .help .the .patient .identify .realistic .outcomes .for .health .problems
ANS: . C
During .the .assessment .phase, .the .nurse .gathers .information .about .the .patient .to .diagnose
.patient .problems. .The .other .responses .are .examples .of .the .planning, .intervention, .and
.evaluation .phases .of .the .nursing .process.
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MULTIPLE .CHOICE
1. The .nurse .completes .an .admission .database .and .explains .that .the .plan .of
.care .and .discharge .goals .will .be .developed .with .the .patient’s .input. .The .patient .states,
.“How .is .this .different .from .what .the .doctor .does?” .Which .response .would .be .most
.appropriate .for .the .nurse .to .make?
a. “The .role .of .the .nurse .is .to .administer .medications .and .other .treatments .prescribed
by .your .doctor.”
b. “The .nurse’s .job .is .to .help .the .doctor .by .collecting .information .and
.communicating
any .problems .that .occur.”
c. “Nurses .perform .many .of .the .same .procedures .as .the .doctor, .but .nurses .are .with
.the
patients .for .a .longer .time .than .the .doctor.”
d. “In .addition .to .caring .for .you .while .you .are .sick, .the .nurses .will .assist .you .to
develop .an .individualized .plan .to .maintain .your .health.”
ANS: . D
This .response .is .consistent .with .the .American .Nurses .Association .(ANA) .definition .of
.nursing, .which .describes .the .role .of .nurses .in .promoting .health. .The .other .responses
.describe .some .of .the .dependent .and .collaborative .functions .of .the .nursing .role .but .do .not
.accurately .describe .the .nurse’s .role .in .the .health .care .system.
2. The .nurse .describes .to .a .student .nurse .how .to .use .evidence-based .practice
.guidelines .when .caring .for .patients. .Which .statement, .if .made .by .the .nurse, .would .be .the
.most .accurate?
a. “Inferences .from .clinical .research .studies .are .used .as .a .guide.”
b. “Patient .care .is .based .on .clinical .judgment, .experience, .and .traditions.”
c. “Data .are .evaluated .to .show .that .the .patient .outcomes .are .consistently .met.”
d. “Recommendations .are .based .on .research, .clinical .expertise, .and .patient .prefer-
ences.”
ANS: . D
Evidence-based .practice .(EBP) .is .the .use .of .the .best .research-based .evidence .combined
.with .clinician .expertise. .Clinical .judgment .based .on .the .nurse’s .clinical .experience .is .part
.of .EBP, .but .clinical .decision .making .should .also .incorporate .current .research .and
.research-based .guidelines. .Evaluation .of .patient .outcomes .is .important, .but .interventions
.should .be .based .on .research .from .randomized .control .studies .with .a .large .number .of
.subjects.
3. The .nurse .teaches .a .student .nurse .about .how .to .apply .the .nursing .process
.when .providing .patient .care. .Which .statement, .if .made .by .the .student .nurse, .indicates .that
.teaching
Downloaded .by: .Kayyh .|
.
Distribution .of .this .document .is .illegal
,was .successful?
a. “The .nursing .process .is .a .scientific-based .method .of .diagnosing .the .patient’s
.health
care .problems.”
b. “The .nursing .process .is .a .problem-solving .tool .used .to .identify .and .treat .patients’
health .care .needs.”
c. “The .nursing .process .is .based .on .nursing .theory .that .incorporates .the .biopsychoso-
cial .nature .of .humans.”
d. “The .nursing .process .is .used .primarily .to .explain .nursing .interventions .to .other
health .care .professionals.”
ANS: . B
The .nursing .process .is .a .problem-solving .approach .to .the .identification .and .treatment .of
.patients’ .problems. .Diagnosis .is .only .one .phase .of .the .nursing .process. .The .primary .use .of
.the .nursing .process .is .in .patient .care, .not .to .establish .nursing .theory .or .explain .nursing
.interven- .tions .to .other .health .care .professionals.
4. A .patient .has .been .admitted .to .the .hospital .for .surgery .and .tells .the .nurse, .“I
.do .not .feel .comfortable .leaving .my .children .with .my .parents.” .Which .action .should .the
.nurse .take .next?
a. Reassure .the .patient .that .these .feelings .are .common .for .parents.
b. Have .the .patient .call .the .children .to .ensure .that .they .are .doing .well.
c. Gather .more .data .about .the .patient’s .feelings .about .the .child-care .arrangements.
d. Call .the .patient’s .parents .to .determine .whether .adequate .child .care .is .being .provid-
ed.
ANS: . C
Since .a .complete .assessment .is .necessary .in .order .to .identify .a .problem .and .choose .an
.appropriate .intervention, .the .nurse’s .first .action .should .be .to .obtain .more .information. .The
.other .actions .may .be .appropriate, .but .more .assessment .is .needed .before .the .best
.intervention .can .be .chosen.
5. A .patient .who .is .paralyzed .on .the .left .side .of .the .body .after .a .stroke
.develops .a .pressure .ulcer .on .the .left .hip. .Which .nursing .diagnosis .is .most .appropriate?
a. Impaired .physical .mobility .related .to .left-sided .paralysis
b. Risk .for .impaired .tissue .integrity .related .to .left-sided .weakness
c. Impaired .skin .integrity .related .to .altered .circulation .and .pressure
d. Ineffective .tissue .perfusion .related .to .inability .to .move .independently
ANS: . C
The .patient’s .major .problem .is .the .impaired .skin .integrity .as .demonstrated .by .the .presence
.of .a .pressure .ulcer. .The .nurse .is .able .to .treat .the .cause .of .altered .circulation .and .pressure
.by .frequently .repositioning .the .patient. .Although .left-sided .weakness .is .a .problem .for .the
.patient,
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.
Distribution .of .this .document .is .illegal
, the .nurse .cannot .treat .the .weakness. .The .“risk .for” .diagnosis .is .not .appropriate .for .this
.patient, .who .already .has .impaired .tissue .integrity. .The .patient .does .have .ineffective .tissue
.perfusion, .but .the .impaired .skin .integrity .diagnosis .indicates .more .clearly .what .the .health
.problem .is.
6. A .patient .with .a .bacterial .infection .has .a .nursing .diagnosis .of .deficient
.fluid .volume .related .to .excessive .diaphoresis. .Which .outcome .would .the .nurse .recognize
.as .most .appropriate .for .this .patient?
a. Patient .has .a .balanced .intake .and .output.
b. Patient’s .bedding .is .changed .when .it .becomes .damp.
c. Patient .understands .the .need .for .increased .fluid .intake.
d. Patient’s .skin .remains .cool .and .dry .throughout .hospitalization.
ANS: . A
This .statement .gives .measurable .data .showing .resolution .of .the .problem .of .deficient .fluid
.volume .that .was .identified .in .the .nursing .diagnosis .statement. .The .other .statements .would
.not .indicate .that .the .problem .of .deficient .fluid .volume .was .resolved.
7. A .nurse .asks .the .patient .if .pain .was .relieved .after .receiving .medication.
.What .is .the .purpose .of .the .evaluation .phase .of .the .nursing .process?
a. To .determine .if .interventions .have .been .effective .in .meeting .patient .outcomes
b. To .document .the .nursing .care .plan .in .the .progress .notes .of .the .medical .record
c. To .decide .whether .the .patient’s .health .problems .have .been .completely .resolved
d. To .establish .if .the .patient .agrees .that .the .nursing .care .provided .was .satisfactory
ANS: . A
Evaluation .consists .of .determining .whether .the .desired .patient .outcomes .have .been .met
.and .whether .the .nursing .interventions .were .appropriate. .The .other .responses .do .not
.describe .the .evaluation .phase.
8. The .nurse .interviews .a .patient .while .completing .the .health .history .and
.physical .examination. .What .is .the .purpose .of .the .assessment .phase .of .the .nursing .process?
a. To .teach .interventions .that .relieve .health .problems
b. To .use .patient .data .to .evaluate .patient .care .outcomes
c. To .obtain .data .with .which .to .diagnose .patient .problems
d. To .help .the .patient .identify .realistic .outcomes .for .health .problems
ANS: . C
During .the .assessment .phase, .the .nurse .gathers .information .about .the .patient .to .diagnose
.patient .problems. .The .other .responses .are .examples .of .the .planning, .intervention, .and
.evaluation .phases .of .the .nursing .process.
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