Chapter 06: Providing Patient-Centered Care Through the Nursing Process
Claywell: LPN to RN Transitions
MULTIPLE CHOICE
1. Which statement by the nurse illustrates how a RN’s patient assessment differs from the LPNs
patient assessment?
a. “The RN gathers basic date for interpretation by the LPN.”
b. “The RN function is to provide assistance with dressing and bathing.”
c. “The RN assesses the patient as a whole and interprets the findings.”
d. “The RN reports abnormal findings to the physician.”
ANS: C
The RN role differs from the LPN role in that the RN: gathers comprehensive date regarding
the patient has a whole and interprets this information, and makes a plan of care for the
patient. The LPN gathers basic data about the patient for the RN to interpret. Both the RN and
LPN can report abnormal findings to the physician.
DIF: Cognitive Level: Evaluation
OBJ: Compare and contrast the responsibilities of the RN with the role of the LPN/LVN in
assessment and developing the plan of care. TOP: Nursing Process
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
2. The nurse is using Gordon’s 11 categories for data collection in performing a health
assessment. Which of the following represents assessment of cognition?
a. How educated is the patient?
b. How does the patient descrN ibe his or her health?
c. Is the patient well nourished?
d. Has the patient had treatment for emotional problems?
ANS: A
Asking the patient’s educational level is an assessment of cognition. How the patient
describes his or her health is an assessment of health perception and health management.
Asking whether the patient is well nourished will assess metabolic pattern, and asking the
patient about treatment for emotional problems will assess the patient’s pattern of coping and
stress tolerance.
DIF: Cognitive Level: Application
OBJ: Discuss the five realms that may affect a patient’s health status that should be addressed in
order to complete a thorough nursing assessment. TOP: Nursing Process
MSC: NCLEX: Psychosocial Integrity
3. The nurse is charting on the patient who is status post-surgery for an abdominal abscess and
notes: “Pt’s temperature has not exceeded 37°C this shift.” This is an example of a(n)
a. intervention.
b. outcome.
c. plan.
d. diagnosis or analysis.
ANS: B
, An outcome measures the effectiveness of the plan of care. An intervention, a plan, and a
diagnosis or analysis are incorrect.
DIF: Cognitive Level: Analysis
OBJ: Compare and contrast the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
4. Which outcome statement is a properly written goal?
a. “The patient will be free of pain.”
b. “The patient will verbalize the importance of lifestyle changes.”
c. “The patient will get up into the chair one time daily for 1 hour.”
d. “The patient will demonstrate breathing techniques by the end of shift.”
ANS: C
To be evaluated, an expected outcome must be specific and measurable, meaning that the
outcomes can be consistently evaluated. “The patient will get up into the chair one time daily
for 1 hour” is specific and measurable. The other outcome statements are vague and open to
interpretation. First, being free from pain may mean absolutely no pain or a tolerable level of
pain. Second, identifying which lifestyle changes are important to teach the patient may differ
from nurse to nurse. Finally, there may be several breathing techniques to teach the patient.
DIF: Cognitive Level: Evaluation
OBJ: Compare and contrast the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
5. The nurse is planning care for a patient with hypertension and obesity. Which of the following
is a reasonable and measurable outcome for the nursing diagnosis of noncompliance with
treatment regimen related to sidNe effects of medications?
a. The patient will state two lifestyle modifications for weight management by (date
certain).
b. The patient will be compliant with the treatment regimen by (date certain).
c. The patient will understand the disease process by (date certain).
d. The patient’s blood pressure will never increase.
ANS: A
The patient’s stating two lifestyle modifications for weight management is reasonable and
measurable. The patient’s being compliant with the treatment regimen is vague. The patient’s
understanding the disease process does not state how the effectiveness of teaching will be
measured (e.g., by return demonstration or verbalization). The patient’s blood pressure not
increasing is not reasonable.
DIF: Cognitive Level: Application
OBJ: Formulate and apply reasonable and measurable outcomes to patient care in the practice setting.
TOP: Nursing Process
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
6. A patient admitted with a diagnosis of Alzheimer’s disease is anxious and dehydrated, has
reportedly not been eating, and has had a weight loss of 5 lb in 1 week. Which nursing
diagnosis is a priority?
a. Dehydration related to fluid loss
b. Inadequate nutrition related to anorexia
Claywell: LPN to RN Transitions
MULTIPLE CHOICE
1. Which statement by the nurse illustrates how a RN’s patient assessment differs from the LPNs
patient assessment?
a. “The RN gathers basic date for interpretation by the LPN.”
b. “The RN function is to provide assistance with dressing and bathing.”
c. “The RN assesses the patient as a whole and interprets the findings.”
d. “The RN reports abnormal findings to the physician.”
ANS: C
The RN role differs from the LPN role in that the RN: gathers comprehensive date regarding
the patient has a whole and interprets this information, and makes a plan of care for the
patient. The LPN gathers basic data about the patient for the RN to interpret. Both the RN and
LPN can report abnormal findings to the physician.
DIF: Cognitive Level: Evaluation
OBJ: Compare and contrast the responsibilities of the RN with the role of the LPN/LVN in
assessment and developing the plan of care. TOP: Nursing Process
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
2. The nurse is using Gordon’s 11 categories for data collection in performing a health
assessment. Which of the following represents assessment of cognition?
a. How educated is the patient?
b. How does the patient descrN ibe his or her health?
c. Is the patient well nourished?
d. Has the patient had treatment for emotional problems?
ANS: A
Asking the patient’s educational level is an assessment of cognition. How the patient
describes his or her health is an assessment of health perception and health management.
Asking whether the patient is well nourished will assess metabolic pattern, and asking the
patient about treatment for emotional problems will assess the patient’s pattern of coping and
stress tolerance.
DIF: Cognitive Level: Application
OBJ: Discuss the five realms that may affect a patient’s health status that should be addressed in
order to complete a thorough nursing assessment. TOP: Nursing Process
MSC: NCLEX: Psychosocial Integrity
3. The nurse is charting on the patient who is status post-surgery for an abdominal abscess and
notes: “Pt’s temperature has not exceeded 37°C this shift.” This is an example of a(n)
a. intervention.
b. outcome.
c. plan.
d. diagnosis or analysis.
ANS: B
, An outcome measures the effectiveness of the plan of care. An intervention, a plan, and a
diagnosis or analysis are incorrect.
DIF: Cognitive Level: Analysis
OBJ: Compare and contrast the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
4. Which outcome statement is a properly written goal?
a. “The patient will be free of pain.”
b. “The patient will verbalize the importance of lifestyle changes.”
c. “The patient will get up into the chair one time daily for 1 hour.”
d. “The patient will demonstrate breathing techniques by the end of shift.”
ANS: C
To be evaluated, an expected outcome must be specific and measurable, meaning that the
outcomes can be consistently evaluated. “The patient will get up into the chair one time daily
for 1 hour” is specific and measurable. The other outcome statements are vague and open to
interpretation. First, being free from pain may mean absolutely no pain or a tolerable level of
pain. Second, identifying which lifestyle changes are important to teach the patient may differ
from nurse to nurse. Finally, there may be several breathing techniques to teach the patient.
DIF: Cognitive Level: Evaluation
OBJ: Compare and contrast the steps of the nursing process. TOP: Nursing Process
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
5. The nurse is planning care for a patient with hypertension and obesity. Which of the following
is a reasonable and measurable outcome for the nursing diagnosis of noncompliance with
treatment regimen related to sidNe effects of medications?
a. The patient will state two lifestyle modifications for weight management by (date
certain).
b. The patient will be compliant with the treatment regimen by (date certain).
c. The patient will understand the disease process by (date certain).
d. The patient’s blood pressure will never increase.
ANS: A
The patient’s stating two lifestyle modifications for weight management is reasonable and
measurable. The patient’s being compliant with the treatment regimen is vague. The patient’s
understanding the disease process does not state how the effectiveness of teaching will be
measured (e.g., by return demonstration or verbalization). The patient’s blood pressure not
increasing is not reasonable.
DIF: Cognitive Level: Application
OBJ: Formulate and apply reasonable and measurable outcomes to patient care in the practice setting.
TOP: Nursing Process
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
6. A patient admitted with a diagnosis of Alzheimer’s disease is anxious and dehydrated, has
reportedly not been eating, and has had a weight loss of 5 lb in 1 week. Which nursing
diagnosis is a priority?
a. Dehydration related to fluid loss
b. Inadequate nutrition related to anorexia
