Question 1

The purpose of the Nursing Outcomes Classification (NOC) is to: (Select all that apply.)

Accepted Answer

A)  validate classification by field test. 
B)  identify labels. 
C)  provide language labels for desired outcomes. 
D)  generate a ready-made nursing care plan for a patient. 
E)  identify patient outcomes and indicators. 
A)  validate classification by field test. 
B)  identify labels. 
C)  provide language labels for desired outcomes. 
D)  generate a ready-made nursing care plan for a patient. 
E)  identify patient outcomes and indicators.

Question 2

After the admission assessment is completed, on subsequent shifts or days, the nurse:

Accepted Answer

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. 
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.

Question 3

A nursing diagnosis identifies: (Select all that apply.)

Accepted Answer

A)  patient's response to illness. 
B)  related signs and symptoms. 
C)  underlying medical diagnosis. 
D)  causative factors. 
E)  potential risk for health problems. 
A)  patient's response to illness. 
B)  related signs and symptoms. 
C)  underlying medical diagnosis. 
D)  causative factors. 
E)  potential risk for health problems.

Question 4

Standardized Nursing Care Plans can:

Accepted Answer

A)  be documented without alteration. 
B)  have items altered or deleted. 
C)  become part of the record without documentation. 
D)  help the family understand the concept of Nursing Care Plans. 
A)  be documented without alteration. 
B)  have items altered or deleted. 
C)  become part of the record without documentation. 
D)  help the family understand the concept of Nursing Care Plans.

Question 5

The nurse should make a point when closing the initial interview to: (Select all that apply.)

Accepted Answer

A)  develop rapport. 
B)  summarize the problems discussed. 
C)  thank the patient for his or her time. 
D)  discuss the nursing goals associated with nursing diagnoses. 
E)  give a copy of the nursing care plan to the patient. 
A)  develop rapport. 
B)  summarize the problems discussed. 
C)  thank the patient for his or her time. 
D)  discuss the nursing goals associated with nursing diagnoses. 
E)  give a copy of the nursing care plan to the patient.

Question 6

The nurse understands that an expected outcome should be: (Select all that apply.)

Accepted Answer

A)  realistic. 
B)  approved by the physician. 
C)  attainable. 
D)  within a defined time. 
E)  included after patient collaboration. 
A)  realistic. 
B)  approved by the physician. 
C)  attainable. 
D)  within a defined time. 
E)  included after patient collaboration.

Question 7

The major goal of the admission interview (usually performed by the RN) is to:

Accepted Answer

A)  establish rapport. 
B)  help the patient understand the objectives of care. 
C)  identify the patient's major complaints. 
D)  initiate nursing care plan forms. 
A)  establish rapport. 
B)  help the patient understand the objectives of care. 
C)  identify the patient's major complaints. 
D)  initiate nursing care plan forms.

Question 8

A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurologic impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.)

Accepted Answer

A)  Assist with range-of-motion exercises every 4 hours and as needed. 
B)  Instruct patient to call for assistance when needing to get out of bed. 
C)  Apply wrist and ankle restraints to promote safety and prevent falls. 
D)  Teach about exercises that will strengthen muscles while lying in bed. 
E)  Ambulate with physical therapy assistance at least three times a day. 
A)  Assist with range-of-motion exercises every 4 hours and as needed. 
B)  Instruct patient to call for assistance when needing to get out of bed. 
C)  Apply wrist and ankle restraints to promote safety and prevent falls. 
D)  Teach about exercises that will strengthen muscles while lying in bed. 
E)  Ambulate with physical therapy assistance at least three times a day.

Question 9

In an acute care facility, a nursing care plan is usually reviewed and updated:

Accepted Answer

A)  every shift. 
B)  every 24 hours. 
C)  once every 3 days. 
D)  on admission and discharge. 
A)  every shift. 
B)  every 24 hours. 
C)  once every 3 days. 
D)  on admission and discharge.

Question 10

The nursing diagnoses that has the highest priority is:

Accepted Answer

A)  Mobility, impaired physical, related to muscular weakness as evidenced by the inability to walk without assistance. 
B)  Communication, impaired verbal, related to neuromuscular weakness as evidenced by facial weakness and inability to speak. 
C)  Imbalanced nutrition: less than body requirements, related to difficulty swallowing and inadequate food intake as evidenced by weight loss of 10 pounds. 
D)  Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating. 
A)  Mobility, impaired physical, related to muscular weakness as evidenced by the inability to walk without assistance. 
B)  Communication, impaired verbal, related to neuromuscular weakness as evidenced by facial weakness and inability to speak. 
C)  Imbalanced nutrition: less than body requirements, related to difficulty swallowing and inadequate food intake as evidenced by weight loss of 10 pounds. 
D)  Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating.

Exam 5: Assessment, Nursing Diagnosis, and Planning

The purpose of the Nursing Outcomes Classification (NOC) is to: (Select all that apply.)

After the admission assessment is completed, on subsequent shifts or days, the nurse:

A nursing diagnosis identifies: (Select all that apply.)

Standardized Nursing Care Plans can:

The nurse should make a point when closing the initial interview to: (Select all that apply.)

The nurse understands that an expected outcome should be: (Select all that apply.)

The major goal of the admission interview (usually performed by the RN) is to:

A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurologic impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.)

In an acute care facility, a nursing care plan is usually reviewed and updated:

The nursing diagnoses that has the highest priority is:

Nursing and the Health Care System

Concepts of Health, Illness, Stress, and Health Promotion

Legal and Ethical Aspects of Nursing

Nursing Process and Critical Thinking

Implementation and Evaluation

Documentation of Nursing Care

Communication and the Nurse-Patient Relationship

Patient Teaching for Health Promotion

Delegation, Leadership, and Management

Growth and Development: Infancy Through Adolescence

Adulthood and the Family

Promoting Healthy Adaptation to Aging

Cultural and Spiritual Aspects of Patient Care

Loss, Grief, the Dying Patient, and Palliative Care

Infection Prevention and Control: Protective Mechanisms and Asepsis

Infection Prevention and Control in the Hospital and Home

Lifting, Moving, and Positioning Patients

Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers

Patient Environment and Safety

Measuring Vital Signs

Assessing Health Status

Admitting, Transferring, and Discharging Patients

Diagnostic Tests and Specimen Collection

Fluid, Electrolyte, and Acid–Base Balance

Concepts of Basic Nutrition and Cultural Considerations

Diet Therapy and Assisted Feeding

Assisting with Respiration and Oxygen Delivery

Promoting Urinary Elimination

Promoting Bowel Elimination

Pain, Comfort, and Sleep

Complementary and Alternative Therapies

Pharmacology and Preparation for Drug Administration

Administering Oral, Topical, and Inhalant Medications

Administering Intradermal, Subcutaneous, and Intramuscular Injections

Administering Intravenous Solutions and Medications

Care of the Surgical Patient

Providing Wound Care and Treating Pressure Ulcers

Promoting Musculoskeletal Function

Common Physical Care Problems of the Elderly

Common Psychosocial Care Problems of the Elderly

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