TOP: Nursing Process: Planning
2 i MSC: NCLEX: Safe and Effective Care Environment
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3. The nurse teaches a student nurse about how to apply the nursing process when providing
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patient care. Which statement, if made by the student nurse, indicates that teaching was s
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uccessful?
a. ―The nursing process is a scientific- 2i 2i 2i 2i 2i
based method of diagnosing the patient‘s health care problems.‖
2i 2i 2i 2i 2i 2i 2i 2i
,[Type here]
2i
Medical-Surgical-Nursing-10th-Edition-Lewis-Test-Bank
b. ―The nursing process is a problem-solving tool used to identify and treat patients‘
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, [Type here]
2i
Medical-Surgical-Nursing-10th-Edition-Lewis-Test-Bank
health care needs.‖ 2i 2i
c. ―The nursing process is used primarily to explain nursing interventions to other
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health care professionals.‖ 2i 2i
d. ―The nursing process is based on nursing theory that incorporates the
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biopsychosocial nature of humans.‖ 2i 2i 2i
ANS: B 2i
The nursing process is a problem-
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solving approach to the identification and treatment of patients‘ problems. Diagnosis is only o
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ne phase of the nursing process. The primary use of the nursing process is in patient care, not t
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o establish nursing theory or explain nursing interventions to other health care professionals.
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TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2 i 2i 2i 2 i 2i 2i 2i 2i 2i
4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not feel com
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fortable leaving my children with my parents.‖ Which action should the nurse take next?
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a. Reassure the patient that these feelings are common for parents. 2i 2i 2i 2i 2i 2i 2i 2i 2i
b. Have the patient call the children to ensure that they are doing well.
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c. Gather more data about the patient‘s feelings about the child-care arrangements.
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d. Call the patient‘s parents to determine whether adequate child care is being
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provided. i
ANS: C 2i
Because a complete assessment is necessary in order to identify a problem and choose an app
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ropriate intervention, the nurse‘s first action should be to obtain more information. The other
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actions may be appropriate, but more assessment is needed before the best intervention can be
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chosen.
DIF: Cognitive Level: Apply (application) 2i 2i 2i REF: 6
OBJ: Special Questions: Prioritization
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TOP: Nursing Process: Assessment
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2i MSC: NCLEX: Psychosocial Integrity
2 i 2i 2i
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer
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on the left hip. Which nursing diagnosis is most appropriate?
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a. Impaired physical mobility related to left-sided paralysis 2i 2i 2i 2i 2i 2i
b. Risk for impaired tissue integrity related to left-sided weakness
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c. Impaired skin integrity related to altered circulation and pressure 2i 2i 2i 2i 2i 2i 2i 2i
d. Ineffective tissue perfusion related to inability to move independently 2i 2i 2i 2i 2i 2i 2i 2i
ANS: C 2i
The patient‘s major problem is the impaired skin integrity as demonstrated by the presence of
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a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by freq
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uently repositioning the patient. Although left-
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sided weakness is a problem for the patient, the nurse cannot treat the weakness. The ―risk for‖
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diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The pat
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ient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates
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more clearly what the health problem is.
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TOP: Nursing Process: Diagnosis
2 i MSC: NCLEX: Physiological Integrity 2i 2i 2 i 2i 2i
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