Nursing Process Practice Questions Quizlet

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The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?

  • A. To gather data about a specific and current health problem.
  • B. To identify life-threatening problems that require immediate attention.
  • C. To compare and contrast current health status to baseline data.
  • D. To establish a database to identify problems and strengths.
Correct Answer: D

Rationale: The correct answer is D: To establish a database to identify problems and strengths. This initial assessment is crucial for gathering comprehensive information about the client's health status, including past medical history, current health problems, and potential risk factors. By establishing a database, the nurse can identify both existing health issues that need to be addressed and strengths that can be built upon for effective care planning. This assessment serves as the foundation for developing an individualized care plan and monitoring the client's progress throughout their hospital stay.

Explanation of other options:
A: To gather data about a specific and current health problem - While this may be part of the assessment process, the main purpose is broader in scope to establish a comprehensive database.
B: To identify life-threatening problems that require immediate attention - While identifying urgent issues is important, the initial assessment is not solely focused on life-threatening problems.
C: To compare and contrast current health status to baseline data - While comparing to baseline data is important for tracking changes, the primary purpose

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The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN

  • A. Assessment
  • B. Diagnosis
  • C. Implementation
  • D. Evaluation
Correct Answer: A

Rationale: The correct answer is A: Assessment. In the scenario, the nurse failed to assess the patient's condition promptly after the patient complained of feeling dizzy and light-headed. Assessment is the first phase of the nursing process and involves collecting data to identify the patient's health status. By not reassessing the patient's vital signs and symptoms, the nurse missed an opportunity to detect the worsening condition. The other choices are incorrect because the error occurred before diagnosis (B), implementation (C), and evaluation (D) phases. In diagnosis, the nurse identifies the patient's problems; in implementation, the nurse carries out the care plan; and in evaluation, the nurse assesses the effectiveness of interventions.

The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN

  • A. Assessment
  • B. Diagnosis
  • C. Implementation
  • D. Evaluation
Correct Answer: A

Rationale: The correct answer is A: Assessment. The nurse made an error in the assessment phase by not communicating the patient's condition promptly. Assessment involves collecting data and recognizing changes in the patient's condition. By not informing the nurse about feeling dizzy and light-headed, the nurse missed crucial information that could have indicated a deteriorating condition. The other choices are incorrect because: B: Diagnosis comes after assessment and involves analyzing data to identify the patient's problems. C: Implementation is the phase where nursing interventions are carried out based on the diagnosis. D: Evaluation is the final phase where the nurse assesses the effectiveness of interventions and outcomes.

Clients will go through operations and who have undergone surgery need the proper observation, treatment, and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria is preparing Mr. Sy for surgery. Which of the following statements by the client would indicate he is well-informed about his imminent surgery?

  • A. “ Right after the operation, I will wear the pneumatic compression device while sitting on the chair.”
  • B. “I will not eat anything after 12 pm the night befire my operation, but I sure can drink.”
  • C. “The skin preparation site is longer and wider than the actual incision site.”
  • D. “I will need to sign the consent from after I get to the operating table.”
Correct Answer: B

Rationale: The correct answer is B. Mr. Sy's statement indicates he understands the pre-operative fasting instructions, which is crucial to prevent aspiration during surgery. Not eating after midnight reduces the risk of complications.

A: Incorrect. Wearing a pneumatic compression device post-surgery is important, but this statement does not demonstrate understanding of pre-surgery preparations.
C: Incorrect. Knowing the skin preparation site size does not indicate understanding of the surgery process.
D: Incorrect. Signing the consent form at the operating table may indicate lack of understanding of the consent process and timing.

In summary, choice B is correct as it shows Mr. Sy's awareness of the fasting requirement before surgery, which is crucial for a safe operation.

Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the

  • A. Frontal lobe
  • B. Six cranial nerve (abducent)
  • C. Occipital lobe
  • D. Eight Cranial Nerve (Vestibulocochlear)
Correct Answer: D

Rationale: The correct answer is D: Eight Cranial Nerve (Vestibulocochlear). Mr. Reyea's complaint of hearing ringing noises indicates a potential issue with his auditory function, which is primarily governed by the Vestibulocochlear nerve. This nerve is responsible for transmitting sound and balance information from the inner ear to the brain. The other choices, A: Frontal lobe, B: Six cranial nerve (abducent), and C: Occipital lobe, are not directly associated with auditory function or the perception of ringing noises in the ear.

The examiner shines a light in the patient’s eyes and notes that the pupils are round and constrict from 4 to 2 mm bilaterally. Next, the examiner asks the patient to focus on a far object, then on the examiner’s finger as it is brought from 3 feet distance to 5 inches distance. The pupils constrict bilaterally and the eyes turn inward. Which of the ff. would be the correct documentation of these findings?

  • A. Pupils 2 mm
  • B. PERRLA
  • C. Pupils constricted
  • D. Pupils normal
Correct Answer: B

Rationale: The correct answer is B: PERRLA, which stands for Pupils Equal, Round, Reactive to Light, and Accommodation. This documentation reflects a comprehensive assessment of the pupils' response to light and accommodation. The pupils constricting from 4 to 2 mm bilaterally in response to light indicates they are reactive. Additionally, the eyes turning inward when focusing on a near object shows accommodation.

Choice A is not the best option because it only mentions the pupil size without capturing other important aspects of the assessment. Choice C is too vague, as it does not specify the exact response of the pupils. Choice D is incorrect because it does not provide a detailed description of the pupils' response to both light and accommodation. Therefore, option B is the most appropriate choice as it encompasses all the necessary components of the assessment.

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