Exam (elaborations)
Chapter 04 The Nursing Process and Critical Thinking
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- Chamberlain School Of Nursing
Chapter 04 The Nursing Process and Critical Thinking
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Chapter 04: The Nursing Process and Critical ThinkingMULTIPLE CHOICE
1. The nurse who uses the nursing process will:
a. help reduce the obvious signs of discomfort.
b. help the patient adhere to the primary care provider’s treatment protocol.
c. approach the patient’s disorder in a step-by-step method.
d. make all significant nursing care decisions involving patient care.
ANS: C
The nursing process is a collaborative process used throughout the patient’s stay. It is an
organized method for identifying and meeting patient needs in a step-by-step manner.
DIF: Cognitive Level: Knowledge REF: p. 48 OBJ: Theory #1
TOP: Nursing Process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. A nurse will arrive at a nursing diagnosis through the nursing process step of:
a. planning.
b. evaluation.
c. research.
d. assessment.
ANS: D
As a result of the nursing assessmN
enUtR, SaIN
nuGrTsB
in.C
gOdM
iagnosis is established.
DIF: Cognitive Level: Comprehension REF: p. 50|Table 4-2
OBJ: Theory #2 TOP: Nursing Diagnosis KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. In the collaborative process of delivering care based on the nursing process, the responsibility
of the LPN/LVN is to:
a. collect data of health status.
b. select a nursing diagnosis.
c. organize data to help the RN evaluate patient progress.
d. prioritize nursing diagnoses for more effective care.
ANS: A
The LPN/LVN collects data of the patient’s health status to assist the RN in selecting a
nursing diagnosis.
DIF: Cognitive Level: Comprehension REF: p. 49|Table 4-1
OBJ: Theory #2 TOP: Critical Thinking KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
4. The participants of the planning stage of the nursing process during which the health goals are
defined include:
a. the RN.
b. the health team led by the RN.
, c. the health team, the patient, and the patient’s family.
d. the health team as directed by the physician.
ANS: C
The planning stage during which the health goals are defined are best shared by the entire
health team, the patient, and the patient’s family for the optimum outcome.
DIF: Cognitive Level: Comprehension REF: p. 48 OBJ: Theory #1
TOP: Nursing Process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
5. When a resident in the nursing home complains of constipation, the nurse performs a digital
rectal examination and finds a hard fecal mass. This is an example of:
a. implementation.
b. nursing diagnosis.
c. assessment.
d. evaluation.
ANS: C
The examination to confirm and affirm the complaint of constipation is an assessment.
DIF: Cognitive Level: Application REF: p. 48|Table 4-1
OBJ: Theory #1 TOP: Nursing Process
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. The nurse completing morning assessments on a patient who is sitting up in bed is told by the
patient, “I’m having trouble breathNiUnR
g— anB’.C
SINIGcT tOseMem to get enough air.” The best nursing
response is to:
a. notify the doctor as soon as he or she comes in later in the morning.
b. finish the vital signs for the assigned patients, and then notify the charge nurse.
c. reassure the patient, if his blood pressure and pulse are normal.
d. notify the charge nurse immediately of the patient’s statement.
ANS: B
The nurse should finish the assessment in order to confirm the complaint and inform the
charge nurse.
DIF: Cognitive Level: Analysis REF: p. 50|Table 4-2
OBJ: Theory #1 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. The order in which the nursing process is approached is:
a. planning, assessment, implementation, nursing diagnosis, evaluation.
b. nursing diagnosis, evaluation, assessment, implementation, planning.
c. assessment, nursing diagnosis, planning, implementation, evaluation.
d. evaluation, nursing diagnosis, planning, implementation, assessment.
ANS: C
The order of assessment nursing diagnosis, planning, implementation, and evaluation sets up a
basis for an organized approach to nursing care.
DIF: Cognitive Level: Knowledge REF: p. 49|Box 4-1
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