Chapter 05: Assessment, Nursing Diagnosis, and Planning Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition

MULTIPLE CHOICE 1. When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _______ data. a. objective b. medical c. subjective d. adjunct ANS: C Subjective data are symptoms that only the patient can identify. DIF: Cognitive Level: Application REF: p. 58 OBJ: Theory #3 TOP: Assessment Data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. The major goal of the admission interview (usually performed by the RN) is to: a. establish rapport. b. help the patient understands the objectives of care. c. identify the patient’s major complaints. d. initiate nursing care plan forms. ANS: C The interview is used as part of the assessment process to elicit information about the patient’s physical, emotional, and spiritual health. DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #1 TOP: Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 3. An example of a structured format for gathering data that aids in forming a database is: a. North American Nursing Diagnosis Association–International (NANDA-I). b. Maslow’s hierarchy. c. QSENl d. Gordon’s 11 Health Patterns. ANS: D Mary Gordon’s assessment guide is a guided path to cover 11 health points. Although Maslow may be used, it is not structured. DIF: Cognitive Level: Knowledge REF: p. 58|Box 5-1 OBJ: Theory # 2 TOP: Gordon’s 11 Health Patterns KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. During the assessment phase of the nursing process, the nurse: a. develops a care plan to meet the patient’s nursing needs. b. begins to formulate plans for providing nursing intervention. c. establishes a nursing diagnosis for the nursing care plan. d. gathers, organizes, and documents data in a logical database. NURSINGTB.COM DEWITS FUNDAMENTAL CONCEPTS AND SKILLS FOR NURSING 5TH EDITION WILLIAMS TEST BANK NURSINGTB.COM ANS: D Gathering and organizing data is the first step in the assessment phase of the nursing process. DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #1 TOP: Data Collection KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 5. After the admission assessment is completed, on subsequent shifts or days, the nurse: a. does not assess the patient again unless the condition changes. b. refers only to the admission assessment during the hospitalization. c. performs a complete physical examination every day. d. assesses the patient briefly in the first hour of the shift. ANS: D The patient should be briefly assessed at the beginning of each shift and more thoroughly if his or her condition changes or as per the plan of care. DIF: Cognitive Level: Comprehension REF: p. 70 OBJ: Theory #1 TOP: Physical Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. The nurse performing an admission interview on an older adult person should: a. rush through the interview to avoid tiring the patient. b. direct questions to the family rather than the patient. c. allow more time for a response to questions. d. prompt the patient to speed recall. ANS: C When interviewing an older adult person, allow more time because the person will probably have a more extensive history and may take a little longer to recall the needed information. DIF: Cognitive Level: Application REF: p. 59 OBJ: Theory #5 TOP: Admission Interview KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity: Basic Care and Comfort