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Chapter 1: An Introduction to Evidence-Based Clinical Practice Guidelines
MULTIPLE CHOICE
• What is the primary purpose of the nursing assessment?
• Identifying underlying pathologic conditions
• Assisting the physician in identifying medical conditions
• Determining the patients mental status
• Exploring patient responses to health problems
ANS: D
A nursing assessment is done to identify the patients response to health
problems. During the nursing assessment phase, a comprehensive
information base is developed through a physical examination, nursing
history, medication history, and professional observation. Identifying
underlying pathologic conditions and assisting the physician in identifying
medical conditions is not part of the nursing process. Determining the
patients mental status is one part of the nursing assessment, but it is not the
primary purpose.
DIF: Cognitive Level: Comprehension
REF: dm 36 OBJ: 1 | 3 TOP: Nursing
Process Step: Assessment
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
• What is the basis of the NANDA I taxonomy?
• Functional health patterns
• Human response patterns
• Basic human needs
• Pathophysiologic needs
ANS: B
The NANDA I taxonomy identifies human response patterns. Functional
components of health patterns are limited to activity, fluid volume,
nutrition, self care, and sensory perception. Basic human needs comprise
less than merely health patterns. Pathophysiologic needs are not part of
the scope of NANDA I
EF: pp. 37-38 OBJ: 5 TOP:
Nursing Process Step: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity
• Which task is included in the assessment step of the nursing process?
• Establishing patient goals/outcomes
• Implementing the nursing care plan (NCP)
• Measuring goal/outcome achievement
• Collecting and communicating data
ANS: D
Data are collected and communicated in the assessment phase of the
nursing process. Establishing goals is the function of planning.
Implementing the NCP is the function of implementation. Measuring
outcome achievement is the function of evaluation.
DIF: Cognitive Level: Comprehension
REF: dm 36 OBJ: 2 | 3 TOP: Nursing
Process Step: Assessment
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
• Which statement regarding nursing diagnoses is accurate?
• Nursing diagnoses remain the same for as long as the disease is present.
• Nursing diagnoses are written to identify disease states.
• Nursing diagnoses describe patient problems that nurses treat.
• Nursing diagnoses identify causes related to illness.
ANS: C
Diagnostic statements identify problems a nurse is independently able to
treat within the scope of professional practice. Nursing diagnoses vary
with the changing condition of the patient. The response patterns are
unique to the patient and are not disease specific. Nursing diagnoses
describe the patients human response pattern.
DIF: Cognitive Level: Comprehension

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