MULTIPLE CHOICE
- The nurse completes an admission database and explains that the plan of care and
discharge goals will be developed with the patient’s input. The patient states, “How is
this different fromwhat the doctor does?” Which response would be most appropriate
for the nurse to make?
a. “The role of the nurse is to administer medications and other treatments
prescribedby your doctor.”
b. “The nurse’s job is to help the doctor by collecting
information andcommunicating any problems that occur.”
c. “Nurses perform many of the same procedures as the doctor, but nurses
are withthe patients for a longer time than the doctor.”
d. “In addition to caring for you while you are sick, the nurses will assist
you todevelop an individualized plan to maintain your health.”
ANS: D
This response is consistent with the American Nurses Association (ANA) definition
of nursing, which describes the role of nurses in promoting health. The other
responses describesome of the dependent and collaborative functions of the
nursing role but do not accurately describe the nurse’s role in the health care
system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: ImplementationMSC: NCLEX: Safe and Effective Care Environment - The nurse describes to a student nurse how to use evidence-based practice
guidelines whencaring for patients. Which statement, if made by the nurse, would
be the most accurate?
a. “Inferences from clinical research studies are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
c. “Data are evaluated to show that the patient outcomes are consistently met.”
d. “Recommendations are based on research, clinical expertise,
and patientpreferences.”
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence
combined withclinician expertise. Clinical judgment based on the nurse’s clinical
experience is part of EBP,but clinical decision making should also incorporate
current research and research-based guidelines. Evaluation of patient outcomes is
important, but interventions should be based onresearch from randomized control
studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 15
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment - The nurse teaches a student nurse about how to apply the nursing process when
providingpatient care. Which statement, if made by the student nurse, indicates
that teaching was successful?
a. “The nursing process is a scientific-based method of diagnosing the
patient’shealth care problems.”
2 / 4
b. “The nursing process is a problem-solving tool used to identify and treat patients’
3 / 4
health care needs.”
c. “The nursing process is used primarily to explain nursing interventions
to otherhealth care professionals.”
d. “The nursing process is based on nursing theory that
incorporates thebiopsychosocial nature of humans.”
ANS: B
The nursing process is a problem-solving approach to the identification and treatment
of patients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of thenursing process is in patient care, not to establish nursing theory or
explain nursing interventions to other health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: ImplementationMSC: NCLEX: Safe and Effective Care Environment - A patient has been admitted to the hospital for surgery and tells the nurse, “I do not
feel comfortable leaving my children with my parents.” Which action should the
nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patient’s feelings about the child-care arrangements.
d. Call the patient’s parents to determine whether adequate child care
is beingprovided.
ANS: C
Because a complete assessment is necessary in order to identify a problem and
choose an appropriate intervention, the nurse’s first action should be to obtain more
information. The other actions may be appropriate, but more assessment is needed
before the best interventioncan be chosen.
DIF: Cognitive Level: Apply (application) REF: 6
OBJ: Special Questions: Prioritization TOP: Nursing Process:
AssessmentMSC: NCLEX: Psychosocial Integrity - A patient who is paralyzed on the left side of the body after a stroke develops a
pressure ulceron the left hip. Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patient’s major problem is the impaired skin integrity as demonstrated by the
presence of a pressure ulcer. The nurse is able to treat the cause of altered
circulation and pressure by frequently repositioning the patient. Although left-sided
weakness is a problem for the patient,the nurse cannot treat the weakness. The “risk
for” diagnosis is not appropriate for this patient,who already has impaired tissue
integrity. The patient does have ineffective tissue perfusion, but the impaired skin
integrity diagnosis indicates more clearly what the health problem is.