1. What are the steps in the nursing process?

 

2.   Mr. Anderson says that his head has been hurting for 3 weeks.  The nurse knows this is what kind of data?

1. Primary objective data
2. Primary subjective data
3. Secondary objective data
4. Secondary subjective data

 

3.    Mr. Jones comes into the doctor’s office with his wife.  During the initial interview with the nurse assessing the reason for the visit, the wife says that her husband has been feeling bad for three days.  The nurse knows this is what type of data?

1. Primary objective data
2. Primary subjective data
3. Secondary objective data
4. Secondary subjective data

 

4.    Pain is always which kind of symptom

1. Subjective
2. Objective

 

5.    Subjective or Objective?

1. Feeling tired
2. Feeling warm skin
3. Seeing spots
4. Seeing a rash
5. A fever
6. Needing to cough
7. Hearing a cough

 

6.    The nurse needs to interview a client in the hospital room.  What is the idea setting for this interview?

7.    What are the 5 types of Nursing Diagnoses?

8.    What is the Basic Three Part Statement format for a Nursing Diagnosis?

9.    What can a Nursing Diagnosis not ever have as the Etiology?

10.  What is different about the format of a Risk Diagnosis compared to an Actual Diagnosis?

11.  What is another name for “defining characteristics”?

12.  What is the proper format of a Nursing Diagnosis that contains a medical diagnosis?

13.  What kind of Nursing Diagnosis uses a One Part Statement?

14.  How do you always start an intervention statement?

15.  How do you always start an outcome or goal statement?

16.  Outcome must always be Smart.  What does this mean?

17.  Which of these is a properly written outcome?

1. The nurse will assist the patient to the nurse’s station twice during this shift.
2. The client will walk unassisted to the bathroom.
3. The client will get out of bed into the chair for two hours today.
4. The client will be free of pain.

 

18.  When does discharge planning begin?

19.  What step in the nursing process does writing desired outcomes occur?

20.  Desired outcomes are based on what part of the Three Part Statement?

21.  Interventions focus on what part of the Three Part Statement?

22.  Which of the following is an not independent nursing intervention?

1. Keep the side rails raised x 2.
2. Give a patient his medication
3. Turn patient every 2 hours
4. Take vital signs every 4 hours

 

23.  What are the two things a nurse must do in the intervention step of the nursing process?

24.  The CNA reports that the patient who is scheduled to be discharge at 11:00 has a blood pressure of 160/90.  What is the nurses first action?

1. Check the medication list to see if there is any medication to give for high blood pressure
2. Check the blood pressure
3. Call the physician
4. Get the charge nurse

 

1. Assess, Diagnose, Plan, Implement, Evaluate
2. B
3. D
4. A
5. .
6. Client in no pain, no TV or other interruptions, should be private, comfortable, seated eye level, at a comfortable distance according to culture, use laymen terminology, or translator as necessary
7. Actual, Risk, Wellness, Possible, Syndrome
8. Problem related to (r/t) Etiology as evidenced by (AEB) defining characteristics (or signs and symptoms)
9. A medical diagnosis

10.  A Risk Diagnosis does not have any defining characteristics, because if it did, it would be an actual problem, not a risk. It is a Two Part Statement.

11.  Signs and symptoms.

12.  Problem r/t Etiology, secondary to Medical Diagnosis, AEB S&S

13.  Wellness, Syndrome

14.  “The nurse will…”

15.  “The patient will…”

16.  Specific, Measurable, Appropriate, Realistic, Timely

17.  C

18.  Upon admission

19.  Planning

20.  Problem

21.  Etiology

22.  B, this is a dependent intervention because it must have a doctor’s order. 

23.  Do the intervention and document the intervention.

24.  B.  The nurse should always validate cues that seem out of the ordinary.  Also in priority questions, the answer is normally an independent nursing intervention first.