Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process?
Identifying major problems or needs
Organizing data in the client’s family history
Establishing short-term and long-term goals
Administering an antibiotic
Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care?
Proposes hypotheses
Generates desired outcomes
Reviews results of laboratory tests
Documents care
Which of the following elements is best categorized as secondary subjective data?
The nurse measures a weight loss of 10 pounds since the last clinic visit.
Spouse states the client has lost all appetite
The nurse palpates edema in lower extremities
Client states severe pain when walking up stairs
The nurse wishes to determine the client’s feelings about a recent diagnosis. Which interview question is most likely to elicit this information?
“What did the doctor tell you about your diagnosis?”
“Are you worried about how the diagnosis will affect you in the future?”
“Tell me about your reactions to the diagnosis.”
“How is your family responding to the diagnosis?”
The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following?
Correlation of the data with other members of the health care team
Demonstration of cost-effective care
Utilization of creativity and intuition in creating a plan of care
Collection of all necessary information for a thorough appraisal
Which of the following is the purpose of assessing?
Establish a database of client responses to his or her health status.
Identify client strengths and problems.
Develop an individualized plan of care.
Implement care, prevent illness, and promote wellness.
In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following?
Collects subjective data
Applies a framework to the collected data
Confirms data is complete and accurate
Records data in the client record
A major characteristic of the nursing process is which of the following?
A focus on client needs
Its static nature
An emphasis on physiology and illness
Its exclusive use by and with nurses
Which of the following would be true regarding use of the observing method of data collection?
When observing, the nurse uses only the visual sense.
Observing is done only when no other nursing interventions are being performed at the same time
Data should be gathered as it occurs, rather than in any particular order.
Observed data should be interpreted in relation to other sources of collected data
Which of the following represent effective planning of the interview setting? Select all that apply.
Keep the lighting dimmed so as not to stress the client’s eyes.
Ensure that no one can overhear the interview conversation.
Stand near the client’s head while he or she is in the bed or chair.
Keep approximately 3 feet from the client during the interview.
Use a standard form to be sure all relevant data are covered in the interview.
