Chapter 12: The Nursing Process and Critical Thinking
Linton: Introduction to Medical–Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. What is the primary purpose of incorporating the nursing process into the care of patients?
a.
Establish a basis of communication with other nursing staff members.
b.
Maintain compliance with existing national nursing standards.
c.
Provide structure and organization to the delivery of medical care to the patient.
d.
Address current health issues, as well as health maintenance and rehabilitation.
2. What is the correct order of the five steps of the nursing process?
a.
Data collection, nursing diagnosis, planning, intervention, and evaluation
b.
Assessment, planning, documentation, intervention, and evaluation
c.
Data collection, diagnosis, assessment, planning, and evaluation
d.
History, physical, diagnosis, intervention, and evaluation
3. What is the basis of the nursing process?
a.
Medical diagnosis of the patient
b.
Identified physiologic and psychologic needs of the patient
c.
Standards of nursing care provided by the American Nurses Association
d.
Orders of the primary care provider
4. Who is responsible for initiating the nursing care plan?
a.
Primary care provider
b.
Registered nurse (RN)
c.
Licensed practical/vocational nurse (LPN/LVN)
d.
Nurse manager
5. What is the most accurate statement about the patient plan of care?
a.
It is continually reviewed and evaluated.
b.
It must be reviewed by the primary caregiver.
c.
It remains in effect until the patient is discharged.
d.
It can only be changed by the initiating nurse.
6. What is the purpose of palpation?
a.
Determining areas of tenderness
b.
Differentiating between fluid- and air-filled organs
c.
Hearing sounds produced by the body
d.
Systematically approaching a physical assessment
7. A patient complains of a headache. What type of data is this information considered?
a.
Subjective
b.
Objective
c.
Pain assessment
d.
Undifferentiated
8. A nurse notes the previous 24-hour urine output was 950 mL, well below the normal of 1500
mL. What is an effective nursing order to remedy the impending dehydration?
a.
Offer more fluids daily.
b.
Offer 8 oz of juice or water at 0800 (8 AM), 1200 (12 noon), 1600 (4 PM), and
2000 (8 PM).
c.
Request extra fluid on a diet tray from the kitchen.
d.
Place a large water pitcher at the bedside during each shift.
9. What sound should a nurse anticipate when percussing a patient’s abdomen?
a.
Flat
b.
Dull
c.
Tympanic
d.
Resonant
10. Which documentation entry reflects objective data?
a.
An area of erythema is noted on the upper right extremity, measuring
approximately 1 4 inches.
b.
The patient complains of pain in the right left quadrant (RLQ) of the abdomen and
rates it 5 on a pain scale of 1 to 10.
c.
The family states that the patient does not sleep at night and wanders around the
house.
d.
The medical history reveals a history of drug abuse.
11. What is a priority nursing action when a postsurgical patient complains of shortness of breath?
a.
Raise the head of the bed to 30 degrees.
b.
Take vital signs.
c.
Perform a focused assessment.
d.
Inform the charge nurse.
12. Which is an example of a complete nursing diagnosis?
a.
Peripheral neurovascular dysfunction
b.
Peripheral neurovascular dysfunction exhibited by patient complaint
c.
Peripheral neurovascular dysfunction related to decreased sensation, exhibited by
the statement “My feet are tingling”
d.
Peripheral neurovascular dysfunction exhibited by patient statement
13. A nurse assisting with prioritizing nursing diagnoses should select which nursing diagnosis as
the highest priority?
a.
Impaired adjustment
b.
Acute pain
c.
Risk for imbalanced body temperature
d.
Ineffective airway clearance
14. Which is the best example of a nursing order?
a.
Perform deep breathing exercises twice daily at 1000 and 1400.
b.
Administer Tylenol every 4 hours as needed for headache.
c.
Assess skin integrity and risk for impairment.
d.
Patient will frequently perform quadriceps-setting exercises.
15. Which statement best describes Nursing Interventions Classifications (NIC)?
a.
They are mandated by the North American Nursing Diagnosis Association
International (NANDA-I) as interventions that are to be used for all patients.
b.
They are currently approved nursing goals.
c.
They are instituted on the basis of individual patient needs.
d.
They are guidelines for goal setting and documentation of nursing care given to
patients.
16. A nurse is aware that a patient goal states, “The patient will eat at least 50% of all meals.” The
nurse has observed the patient eating more than 50% of all meals for 2 days. What is the most
accurate evaluation statement?
a.
Ate well for all meals.
b.
Problem is resolved; goal is met.
c.
Goal is met; patient ate 50% of all meals on 7/12 and 7/13.
d.
Ate 50% of meals.
17. What elements should be included in data collection?
a.
Information supplied by patient and family
b.
Health history, physical assessment, and documentation
c.
Health history and physical assessment
d.
Assessment, patient records, and diagnostic tests
18. When reviewing a patient care plan the nurse reads that “the patient will maintain an adequate
nutritional state without nausea or vomiting.” What does this statement represent?
a.
Intervention
b.
Process
c.
Diagnosis
d.
Goal
19. What is the Nursing Outcomes Classification (NOC) a method of classifying?
a.
Nursing process
b.
Nursing care plan
c.
Nursing goal
d.
Nursing intervention outcome
20. What are standardized care plans considered?
a.
Clinical pathways
b.
Evaluation tools
c.
Outcome criteria
d.
Nursing intervention based
21. What should documentation include?
a.
Objective and subjective data
b.
Observations made by other nursing staff
c.
Information that is accurate and complete
d.
Incidence reports
22. Which is the most accurate example of documentation?
a.
7/27/14; 0945; pt. vomited; pt. looked better after episode—A. Nurse, LPN
b.
7/27/14; 0945; pt. vomited large amount; reduced nausea
c.
7/27/14; 0945; pt. reported less nausea after vomiting—A. Nurse, LPN
d.
7/27/14; 045; pt. vomited 200 ml of partially digested food; pt. states nausea has
diminished—A. Nurse, LPN
23. What is true regarding problem-oriented medical records (POMRs)?
a.
The focus is on patient response to treatment.
b.
They are considered source-oriented charting.
c.
They reflect the patient’s current problems.
d.
They focus on medical diagnosis.
24. What elements are included in the characteristics of critical thinking?
a.
Interpretation, analysis, and evaluation
b.
Patient-centered criteria and problem solving
c.
Realistic outcomes and frequent evaluation
d.
Data gathering and assessment
25. Why is critical thinking an integral part of the nursing process?
a.
It promotes flexibility and individualized care.
b.
It incorporates decision making.
c.
It includes the patient in part of the nursing process.
d.
It provides guidelines of care.
MULTIPLE RESPONSE
26. What actions should a nurse implement when auscultating a patient’s chest? (Select all that
apply.)
a.
Use the diaphragm for assessing breath sounds.
b.
Use the bell for assessing murmurs.
c.
Apply earpieces pointing toward the ears.
d.
Wet the chest hair with a cloth.
e.
Press the diaphragm very firmly against the chest wall.
27. In what ways does evidence-based practice support effective nursing care? (Select all that
apply.)
a.
Research on nursing care topics
b.
Directives from the boards of nursing
c.
Summation of studies
d.
Recommendations for nursing care
e.
Funding research
COMPLETION
28. In PIE documentation, a type of POMR, the acronym PIE stands for _____, _____, and
_____.
29. Examine this goal statement: Patient will walk in the hall unassisted. The two missing
components for a correctly stated goal in this example are the descriptors for _____ and
_____.
30. A nurse who exhibits an open minded, professionally curious, mature, and self-confident
approach to care would be considered a(n) _____.