Exam (elaborations)
Chapter 05 Assessment, Nursing Diagnosis, and Planning
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- Chamberlain School Of Nursing
Chapter 05 Assessment, Nursing Diagnosis, and Planning
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Chapter 05: Assessment, Nursing Diagnosis, and PlanningMULTIPLE CHOICE
1. When the patient complains of nausea and dizziness, the nurse recognizes these complaints as
data.
a. objective
b. medical
c. subjective
d. adjunct
ANS: C
Subjective data are symptoms that only the patient can identify.
DIF: Cognitive Level: Application REF: p. 58 OBJ: Theory #3
TOP: Assessment Data KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. The major goal of the admission interview (usually performed by the RN) is to:
a. establish rapport.
b. help the patient understands the objectives of care.
c. identify the patient’s major complaints.
d. initiate nursing care plan forms.
ANS: C
The interview is used as part of thNe UaR
ssSeIsNsGmTeBn.C
t pOrM
ocess to elicit information about the patient’s
physical, emotional, and spiritual health.
DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #1
TOP: Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
3. An example of a structured format for gathering data that aids in forming a database is:
a. North American Nursing Diagnosis Association–International (NANDA-I).
b. Maslow’s hierarchy.
c. QSENl
d. Gordon’s 11 Health Patterns.
ANS: D
Mary Gordon’s assessment guide is a guided path to cover 11 health points. Although Maslow
may be used, it is not structured.
DIF: Cognitive Level: Knowledge REF: p. 58|Box 5-1
OBJ: Theory # 2 TOP: Gordon’s 11 Health Patterns KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
4. During the assessment phase of the nursing process, the nurse:
a. develops a care plan to meet the patient’s nursing needs.
b. begins to formulate plans for providing nursing intervention.
c. establishes a nursing diagnosis for the nursing care plan.
d. gathers, organizes, and documents data in a logical database.
, ANS: D
Gathering and organizing data is the first step in the assessment phase of the nursing process.
DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #1
TOP: Data Collection KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
5. After the admission assessment is completed, on subsequent shifts or days, the nurse:
a. does not assess the patient again unless the condition changes.
b. refers only to the admission assessment during the hospitalization.
c. performs a complete physical examination every day.
d. assesses the patient briefly in the first hour of the shift.
ANS: D
The patient should be briefly assessed at the beginning of each shift and more thoroughly if
his or her condition changes or as per the plan of care.
DIF: Cognitive Level: Comprehension REF: p. 70 OBJ: Theory #1
TOP: Physical Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. The nurse performing an admission interview on an older adult person should:
a. rush through the interview to avoid tiring the patient.
b. direct questions to the family rather than the patient.
c. allow more time for a response to questions.
d. prompt the patient to speed recall.
ANS: C NURSINGTB.COM
When interviewing an older adult person, allow more time because the person will probably
have a more extensive history and may take a little longer to recall the needed information.
DIF: Cognitive Level: Application REF: p. 59 OBJ: Theory #5
TOP: Admission Interview KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. A nursing diagnosis consists of:
a. the health care provider’s medical diagnosis listed as the nursing diagnosis.
b. diagnostic labels formulated by the North American Nursing Diagnosis
Association–International (NANDA-I).
c. the patient’s explanation of his or her “chief complaint” or “current complaint.”
d. the results of the nursing assessment without consideration of doctor’s orders.
ANS: B
NANDA-I has formulated an official list of nursing diagnoses to identify patient problems and
problems that patients are at risk of developing. A nursing diagnosis is independent of a
medical diagnosis.
DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: Theory #5
TOP: Nursing Diagnosis KEY: Nursing Process Step: Planning
MSC: NCLEX: N/A
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