Which of the following behaviors would indicate the nurse was utilizing the assessment phase of the nursing process to provide nursing care?

Objectives (Syllabus pg 12)

•Describe the components of the Functional Health Assessment.
•Describe the interrelationships among the steps of the nursing process.
•Describe the method for formulating nursing diagnoses to reflect the patient's health state.
•Identify subjective and objective assessment data.
•Cluster related data from the FHP using a concept map.
•Develop nursing diagnosis from case study assessment data.
•Prioritize nursing diagnoses.

Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process?

1. Identifying major problems or needs.
2. Organizing data in the client's family history.
3. Establishing short term and long term goals.
4. Administering an antibiotic.

1
Rationale:
Identifying problems/needs is part of nursing diagnosis. For example, a client with difficulty breathing would have Impaired Gas Exchange related to constricted airways as manifested by shortness of breath (dyspnea) as a nursing diagnosis.

Organizing the family history is part of the assessment phase (#2). Establishing goals is a part of the planning phase (#3). Administering an antibiotic is part of the implementation phase (#4).

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process, to provide nursing care?

1. Propose hypotheses
2. Generate desired outcomes
3. Reviews results of laboratory tests
4. Documents care

3
Rationale:
During assessment, data are collected, organized, validated, and documented.

Hypotheses are generated during diagnosing (#1).
Outcomes are set during planning (#2) Documentation occurs throughout the nursing process (4).

Which of the following elements is best categorized as secondary subjective data?

1. The nurse measures a weight loss of 10 pounds since the last clinic visit.
2. Spouse states the client has lost all appetite.
3. The nurse palpates edema in lower extremities.
4. Client states severe pain when walking up stairs.

2
Rationale:
Secondary data comes from any other source (chart, family) besides the client. Subjective data are covert (reported or an opinion).

Weight is objective data that can be measured or validated (#1). Edema is objective data that can be measured or validated (#3). What the client reports is primary data (#4).

The nurse wishes to determine the client's feelings about a recent diagnosis. Which interview question is most likely to elicit this information?

1. "What did the doctor tell you about your diagnosis?"
2. "Are you worried about how the diagnosis will affect you in the future?"
3. "Tell me about your reactions to the diagnosis."
4. "How is your family responding to the diagnosis?"

3
Rationale:
Eliciting feelings requires an open-ended questions that seeks more than just factual information and cannot be answered with a single word.

This question just seeks factual information (#1). This question can be answered with a single word (#2). The family can provide indirect information about the client but is not most likely to provide the most accurate information (#4).

The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following?

1. Correlation of the data with other members of the health care team.
2. Demonstration of cost-effective care.
3. Utilization of creativity and intuition in creating a plan of care.
4. Collection of all necessary information for a thorough appraisal.

4
Rationale:
Correct. Frameworks help the nurse be systematic in data collection.

Other members of the health care team may use very different conceptual organizing frameworks so data may not correlate (#1). Cost-effective care is more likely to occur with systematic application of the nursing process, but use of a framework for assessment alone may not accomplish this goal (#2). Because the framework is structured and because of the nature of client needs/problems, creativity and intuition in care planning are not assured (#3).

The nurse is conducting the diagnosing phases (nursing diagnosis) of the nursing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement?

1. Assess the client's needs.
2. Delineate the client's problems and strengths.
3. Determine which interventions are most likely to succeed.
4. Estimate the cost of several different approaches.

2
Rationale:
In diagnosing, data from assessment (#1) are analyzed and problems, risks, and strengths are identified before diagnostic statements can be established.

This is assessment (#1). Interventions are more commonly part of the planning and implementing phases of the nursing process (#3). Cost is an important consideration but would be estimated in the planning phase (#4).

In the diagnostic statement "Excess fluid volume related to decreased venous return as manifested by lower extremity edema (swelling)," the etiology of the problem is which of the following?

1. Excess fluid volume
2. Decreased venous return
3. Edema
4. Unknown

2
Rationale:
Because the venous return is impaired, fluid is static, resulting in swelling. Therefore, decreased venous return is the cause (etiology) of the problem.

Excess Fluid Volume is the nursing diagnosis (#1). Edema of the lower extremity is the sign/symptom or critical attribute (#3).The cause is known (#4).

Which of the following nursing diagnoses contains the proper components?

1. Risk for caregiver role strain related to unpredictable illness course
2. Risk for falls related to tendency to collapse when having difficulty breathing
3. Impaired communication related to stroke
4. Sleep deprivation secondary to fatigue and a noisy environment

1
Rationale:
States the relationship between the stem (caregiver role strain) and the cause of the problem.

The diagnostic statement says the same thing as the related factor (falls and collapse) (#2). It is inappropriate to use medical diagnoses such as stroke within a nursing diagnosis statement (#3). #4 is vague. The statement must be specific and guide the plan of care (fatigue may be a result of sleep deprivation and does not direct intervention).

One of the primary advantages of using a three-part diagnostic statement such as the problem-etiology-signs/symptoms (PES) format includes which of the following?

1. Decreases the cost of health care
2. Improves communication between nurse and client
3. Helps the nurse focus on health and wellness elements
4. Standardizes organization of client data

4
Rationale:
The PES format assists with comprehensive and accurate organization of client data.

More efficient planning may or may not reduce health care cost (#1). Nursing diagnostic statements should be confirmed with the client but using PES does not ensure this (#2). PES statements can be wellness or illness focused (#3).

Which of the following is the purpose of assessing?

1. Establish a database of client responses to his or her health status.
2. Identify client strengths and problems.
3. Develop an individualized plan of care.
4. Implement care, prevent illness, and promote wellness.

1
Rationale:
Assessing provides a database of the client's physiological and psychosocial responses to his or her health status.

Client strengths and problems (#2) are identified in the diagnosing phase of the nursing process, a care plan is established (#3) in the planning phase, and care, prevention, and wellness promotion (#4) are part of the implementing phase.

In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following?

1. Collects subjective data
2. Applies a framework to the collected data
3. Confirms data is complete and accurate
4. Records data in the client record

3
Rationale:
In validating, the nurse confirms that data is complete and accurate.

Subjective data is collected in the collecting activity (#1), a framework is applied to the data in the organizing activity ( #2), and data is recorded in the documenting activity (#4).

A major characteristic of the nursing process is which of the following?

1. A focus on the client needs
2. Its static nature
3. An emphasis on physiology and illness
4. Its exclusive use by and with nurses

1
Rationale:
The nursing process focuses on client needs.

It is dynamic rather than static (#2), emphasizes client response rather than physiology and illness (#3), and is collaborative rather than used exclusively by nurses (#4).

Which of the following would be true regarding use of the observing method of data collection?

1. When observing, the nurse uses only the visual sense.
2. Observing is done only when no other nursing interventions are being performed at the same time.
3. Data should be gathered as it occurs, rather than in any particular order.
4. Observed data should be interpreted in relation to other sources of collected data.

4
Rationale:
Interpreting collected data is necessary to help validate its accuracy.

Observing includes the senses of smell, hearing, and touch in addition to vision (#1). Using priority setting, observing must often be performed simultaneously with other activities (#2). A systematic approach to observing data helps ensure nothing is missed and the nurse pays attention to the most important data first (#3).

Which of the following represent effective planning of the interview setting? Select all that apply.

1. Keep the lighting dimmed so as not to stress the client's eyes.
2. Ensure that no one can overhear the interview conversation.
3. Stand near the client's head while he or she in in the bed or chair.
4. Keep approximately 3 feet away from the client during the interview.
5. Use a standard form to be sure all relevant data are covered in the interview.

2, 4, & 5
Rationale:
The nurse plans the interview so that privacy is observed. A comfortable distance between nurse and client to respect the client's personal space is about 3 feet. Using a standard form will help ensure the nurse doesn't omit gathering any vital information.

Lighting should be at a normal level - neither bright nor dim (#1). The nurse should be at the same height as the client, usually siting, at approximately a 45-degree angle facing the client. The nurse standing over the client creates an uncomfortable atmosphere for an interview (#3).

A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis

1. If both medical and nursing interventions are required to treat the problem.
2. When independent nursing actions can be utilized to treat the problem.
3. In cases where nursing interventions are the primary actions required to treat the problem.
4. When no medical diagnosis (disease) can be determined.

1
Rationale:
A collaborative (multidisciplinary) problem is indicated when both medical and nursing interventions are needed to prevent or treat the problem. If nursing care alone (whether that care involves independent or dependent nursing actions) can treat the problem, a nursing diagnosis is indicated. If medical care alone can treat the problem, a medical diagnosis is indicated.

In the case in which a client is vulnerable to developing a health problem, the nurse chooses which type of nursing diagnosis (dx) status?

1. A risk nursing dx
2. A wellness nursing dx
3. A health promotion nursing dx
4. An actual nursing dx

1
Rationale:
A risk nursing dx is appropriate when the evidence for the problem indicates that a condition exists that makes the client vulnerable to a problem.

A wellness dx is used when enhancement of the client's already healthy responses is indicated (#2). Health promotion dxs are used when the client seeks to increase well-being but need not currently be well (#3). An actual dx is used when the client already exhibits the new problem (#4).

Which of the following is true regarding the state of the science in regards to nursing diagnosis?

1. The original taxonomy has proven to be adequate in scope.
2. The organizing framework of the taxonomy is based on the work of Florence Nightingale.
3. More research is needed to validate and refine the diagnostic labels.
4. New diagnostic labels are approved by means of a vote of RNs.

3
Rationale:
Diagnostic labels are continuously reviewed and revised as indicated by research - much more of which is needed.

The original taxonomy has been replaced by taxonomy 2 and is no longer based on a nurse theorist (#1 & #2). New dxs are approved by NANDA International's Diagnostic Review Committee, not by a vote of nurses (#4).

Which of the following would indicate a significant cue when comparing data to standards? Select all that apply.

1. The client has moved partway toward a set goal (ex: weight loss)
2. The client's vision is within normal range only when wearing glasses.
3. A child is able to control bladder and bowels at age 18 months.
4. A woman widowed recently states she is "unable to cry".
5. A 16-year-old high school student reports spending 6 hours doing homework five nights per week.

1, 4, & 5
Rationale:
A client's movement toward a goal (#1) or whose behavior is inconsistent with population norms (#4 & #5) represents a cue that further analysis toward creating a nursing dx is required.

Corrected vision (#2) and bladder and bowel control at 18 mos (#3) are consistent with population norms.

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide the nursing care?

Which of the following would the nurse perform during the assessment phase of the nursing process?

Which of the following will the nurse perform in the validating activity of the assessing phase of the nursing process?

What activities are performed during the assessment phase of the nursing process quizlet?