Test Bank - Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice 10th
Chapter 11: Assessing
Question 1
Type: MCSA
The student is learning the steps of the nursing process. What is the first thing that the student should realize
about the purpose of this process?
1. Deliver care to a client in an organized way.
2. Implement a plan that is close to the medical model.
3. Identify client needs and deliver care to meet those needs.
4. Make sure that standardized care is available to clients.
Correct Answer: 3
Rationale 1: Delivery of organized care is not part of the nursing process, although each phase is interrelated.
Rationale 2: The nursing process is not part of the medical model, as nurses treat the clients response to the
disease or problem.
Rationale 3: The purpose of the nursing process is to identify a clients health status and actual or potential
health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing
interventions to meet those needs.
Rationale 4: The nursing process is individualized for each clients care plan. It is not about standardizing care.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral,
psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in
patients, using developmentally and culturally appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Describe the phases of the nursing process.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.
Page Number: 155
Question 2
Type: MCSA
While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the
tape used to secure the dressing. In which phase of the nursing process is the nurse working?
,Test Bank - Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice 10th
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Correct Answer: 1
Rationale 1: Assessment is the collection, organization, validation, and documentation of data. Assessment is
carried throughout the nursing process, as in this case. Even though performing the dressing change is
implementation, noticing the new skin breakdown is assessment.
Rationale 2: Diagnosis is identifying the clients response to the problem. Implementation is what the nurse
does to help the client reach a goal, and then the goal is evaluated.
Rationale 3: Even though performing the dressing change is implementation, noticing the new skin breakdown
is assessment.
Rationale 4: The goal of the intervention is evaluated, but that is not what is being described in this scenario.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral,
psychological, spiritual,
socioeconomic, and environmental assessments of health and illness parameters in patients, using
developmentally and culturally appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. Identify the four major activities associated with the assessing phase.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.
Page Number: 159
Question 3
Type: MCSA
During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and
says leave me alone. Which subjective data should the nurse document?
1. Restlessness
2. Leave me alone
3. Not talkative
, Test Bank - Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice 10th
4. Pale and diaphoretic
Correct Answer: 2
Rationale 1: Restlessness is observable so it is not subjective data.
Rationale 2: Subjective data can be described or verified only by that person and are apparent only to the
person affected. Subjective data include the clients sensations, feelings, beliefs, attitudes, and perceptions of
personal health status and life situations.
Rationale 3: Not being talkative is observable so it is not subjective data.
Rationale 4: Paleness with diaphoresis is observable so this is not subjective data.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral,
psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in
patients, using developmentally and culturally appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.
Page Number: 160
Question 4
Type: MCSA
Family of a client demonstrating confusion state that this is not the clients usual behavior. How should the
nurse document this data?
1. Inference
2. Subjective data
3. Objective data
4. Secondary subjective data
Correct Answer: 3
Rationale 1: Inference is making a judgment, and that is not what is described in the question.
Rationale 2: The information provided by the spouse is not subjective because it is an observation by someone
familiar with the clients usual behavior.
Rationale 3: Information supplied by family members, significant others, or other health professionals are
