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1.What is the rationale for using the nursing process in planning care for clients?
A. As a scientific process to identify nursing diagnoses of a clients' healthcare problems.
B. To establish nursing theory that incorporates the biopsychosocial nature of humans.
C. As a tool to organize thinking and clinical decision making about clients' healthcare
needs.
D. To promote the management of client care in collaboration with other healthcare
professionals. - Answer - C (The nursing process is a problem-solving approach that
provides an organized, systematic, decision making process to effectively address the
client's needs and problems. The nursing process includes an organized framework
using knowledge, judgments, and actions by the nurse as the client's plan of care is
determined, and encompasses assessment, analysis, planning, implementation, and
evaluation of client care (C). (A, B, and D) do not support the basis for using the nursing
process.
Correct Answer: C)
2.What activity should the nurse use in the evaluation phase of the nursing process?
A. Ask a client to evaluate the nursing care provided.
B. Document the nursing care plan in the progress notes.
C. Determine whether a client's health problems have been alleviated.
D. Examine the effectiveness of nursing interventions toward meeting client outcomes. -
Answer - In the nursing process, the evaluation component examines the effectiveness
of nursing interventions in achieving client outcomes (D). (A) is an evaluation of client
satisfaction, not outcomes. (B) is a written record of the plan of care. Although (C) may
occur when client outcomes are achieved, evaluation is best determined by attainment
of measurable client outcomes.
Correct Answer: D
3.Which statement is an example of a correctly written nursing diagnosis statement?
A. Altered tissue perfusion related to congestive heart failure.
B. Altered urinary elimination related to urinary tract infection.
C. Risk for impaired tissue integrity related to client's refusal to turn.
D. Ineffective coping related to response to positive biopsy test results. - Answer - The
first part of the nursing diagnosis statement is the diagnostic label and is followed by
related to the cause, which should direct the nurse to the appropriate interventions. (D)
best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable
cause, but (D) focuses on the client's response, which the nurse can provide support,
reflection, and dialogue.
Correct Answer: D
4.What action by the nurse demonstrates culturally sensitive care?
A. Asks permission before touching a client.
B. Avoids questions about male-female relationships.
C. Explains the differences between Western medical care and cultural folk remedies.
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