Sat Exam-nrsg Process

A client comes in a clinic with reports of abdominal pain and diarrhea. While taking the client’s vital signs, the nurse is implementing which phase of the nursing process? a) b) c) d)

Assessment Diagnosis Planning Implementation

1. The nurse is measuring the client’s urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? a) The client reports abdominal pain- subjective b) The client urine output was 450ml c) The client’s states, “ I didn’t see any stones in my urine.” d) The client’s states, “I feel like I have passed a stone.” 2. When evaluating an elderly client’s blood pressure of 145/80mmHg, the nurse does which of the following before determining whether the Bp is normal or represents hypertension? a) Compare this reading against defined standards b) Compare the reading with one taken in the opposite arm c) Determine gaps in the vital signs data in the client record. d) Compare the current measurement with previous ones 3. The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to: a) Diagnose if the patient is at risk for falls b) Ensure that the patient’s skin is intact c) Establish a therapeutic relationship d) Identify important data 4. The nurse understands that evaluation most directly relates to which aspect of the nursing process? a) Goal b) Problem c) Etiology d) Implementation 5. The nurse comes to the conclusion that a patient’s elevated temperature, pulse and respiration are significant. What step of the nursing process is being used when the nurse comes to this conclusion? a) Implementation b) Assessment c) Evaluation d) Diagnosis 6. When the nurse considers the Nursing Process, the word “identify” is to “recognize” as the word “do” is to? a) Plan b) Evaluate c) Diagnose

d) Implement7. The nurse is collecting subjective data associated with a patient’s anxiety. Which assessment method should be used to collect this information? a) Observing b) Inspecting c) Auscultation d) Interviewing 8. The nurse collects objective data when a hospitalized patient states: a) “I’am hungry” b) “I feel very warm” c) “I ate half my lunch” d) “I have the urge to urinate” 9. During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are achieved? a) Implementation b) Evaluation c) Diagnosis d) Planning 10.When considering the nursing process, the nurse understands that the word “observe” is to “assess” as the word “determine” is to? a) Plan b) Analyze c) Diagnose d) Implement 11.Critical thinking is necessary to: a) Plan nursing care b) Organize care for several patients c) Collaborate with others d) Draw sound conclusions from assessment data 12.The use of critical thinking particularly helps nursing students: a) Get along with classmates and colleagues b) Develop clinical judgement needed for safe practice c) Gather sufficient assessment data d) Learn to effectively interact with other people 13.Problem solving involves: a) Setting priorities for tasks b) Organizing the workload c) Considering alternatives of action d) Collaborating with other people

14.Which one of the following is the etiologic factor in the nursing diagnosis “Impaired physical mobility related to left sided muscular weakness as evidenced by the inability to bear weight on the left leg”? a) Impaired physical mobility b) Left sided muscular weakness c) As evidenced by d) Inability to bear weight on the left leg 15.An example of an approved, correctly written nursing diagnosis for the patient is: a) Pain r/t abdominal surgery as evidenced by surgical report b) Risk for injury r/t neurological impairment as evidenced by paralysis of right leg c) Risk for fluid deficit r/t nausea and vomiting d) Constipation r/t complaint of no Bowel movement yesterday 16.Mhy ‘s temperature is 100.4 Fahrenheit. The skin on her forehead is warm and dry. She has been incontinent and her bed is wet. She is complaining of being tired. Which of the data is subjective? a) Temperature 100.4 Fahrenheit b) Skin warm and dry c) Bed is wet d) Complains of being tired 17.You want to know something about the patient’s spirituality. You would first look for any noted religious preference: a) In the nursing assessment b) On the face sheet c) In the physician’s history and physical d) On the physical examination form 18.Which one of the following is stated as a goal rather than an expected outcome? a) Patient will resume full job activities within 3 weeks b) Patient will perform exercises three times a day c) Patient will regain use of left arm and leg d) Physical therapist will instruct patient in use of walker before discharge 19.Which one of the following is a correctly stated expected outcome? a) Walk a half mile without shortness of breath b) Patient will demonstrate correct use of incentive spirometer within 24 hours c) Patient will resume normal activities d) Doctor will discharge patient within 4 days 20.The establishment of data base for a newly admitted patient forms which phase of the nursing process? a) Assessment b) Implementation c) Diagnosing d) Planning

21.Assessment phase of the nursing process is completed: a) At the beginning of every shift b) In the terminating phase of the nurse-patient relationship c) On the initial nurse-patient relationship d) At the beginning and end of each shift 22.A nurse who is taking care of a patient with severe dehydration decided to first provide liquids and gave health instructions on sanitation and hygiene. What is the nurse doing in the element of nursing process? a) Implementations b) Evaluation c) Planning d) Assessment 23. It is the comprehensive approach of collecting data to identify possible nursing problems is processed through? a) Assessment b) Evaluation c) Analysis d) Nursing diagnosis 24.In taking care of patients for cardiac catheterization, the nurse noted that the patient manifested fear related to cardiac catheterization and its outcome, this statement is an example of: a) Nursing diagnosis b) Implementation c) Evaluation d) Intervention 25. Which is a Subjective data? a) Pulse rate b) Pain c) Wound healing d) Nursing process 26.Through the course of Jack’s interaction with the family, he learned that the couple has 6 children, 2 of which are in the secondary, 3 in the elementary and the three-year old baby stays at home. In addition, he learned that the family’s income is about P400/day. Jack is utilizing what type of assessment? a) Interview b) Record Review c) Observation d) Physical Assessment 27.When Jack roamed around the community to visit other families, one of the mothers approached him and told him that her child is having colds and fever. Jack examined the child and took the child’s vital signs. Jack utilizes which of the following types of data gathering? a) Observation b) Laboratory examination

c) Record review d) Physical assessment 28.What are primary sources of information? a) Surveys b) Charters c) Wills d) Hearsays 29. What is not a device used to record information? a) Rating Scale b) Score Card c) Scaled Specimen d) Interview 30.During his immersion with Aling Isabella’s family, Edward learned that she has 5 children, 1 is in the secondary, 3 in the elementary and a three-year old baby. He also found out in their conversation that her daily income for doing laundry is 250php/day. What technique did Edward perform in gathering data? a. b. c. d.

Inquiry Forms Interview Observation Physical Assessment

31.Edward also noticed that Aling Isabella’s three year-old baby has colds and fever. He examined the child and took the vital signs. Edward’s action is an example of? a. Physical Assessment b. Observation c. Interview d. Record review 32.Edward went back to the health center to retrieve the interview questionnaire answered by the family. Jack is utilizing which type of data gathering? a. Observation b. Physical assessment c. Record review d. Interview 33.Edward is a student nurse. During his duty in the health center, she met Aling Isabella and her family. Aling Isabella stated “Nilalagnat ako tuwing gabi at wala rin akong ganang kumain.” Her statement is an example of what data? a First level assessment b Second level assessment c Objective cue d Subjective cue 34.After identifying the health problems, Edward proceeds to the second level assessment. The product of second level assessment is? a Objective and subjective cues b Nursing diagnosis c Formulation of goals

d

Formulation of objectives

35.Data gathering method which is done through inspection, palpation, percussion, auscultation, measurement of specific body parts and reviewing the body systems. a Observation b Record Review c Interview d Physical Examination 36.It refers to more specific statement of the desired result or outcomes of care: a. b. c. d.

objectives evaluation goal skills

37.The comprehension and interpretation of patient’s data to identify possible nursing problems is processed through: a. b. c. d.

Assessment Evaluation Analysis Nursing diagnosis

38. In taking care of a patient for surgery, the nurse noted that the patient manifested fear related to surgery and its possible outcome. This statement is an example of: a. b. c. d.

Nursing diagnosis Implementation Assessment Evaluation

39. These statements about nursing diagnosis are true except: a. b. c. d.

Nursing diagnosis states the etiology of the problem Nursing diagnosis is disease oriented Nursing diagnosis guides independent nursing action Nursing diagnosis is complimentary to medical diagnosis

40.The Nursing Process is defined as: a) a systematic, organized, rational method of planning and providing individualized, humanistic nursing care. b) a systematic, not organized, rational method of planning and providing individualized, unhumanistic nursing care c) Adaptation of problem-solving techniques and decision making principles in all the phases d) Serves as a framework for accountability through documentation

41.The following are parts of a nursing process except: a) Assessment Phase b) Diagnosing Phase c) Planning Phase d) Intervene Phase 42.This is to create a data base for problem identification: what type of assessment is it? a) Emergency Assessment b) Focus Assessment or On-going Assessment c) Initial Assessment d) Time-Lapsed Assessment 43.The following are methods of date collection except? a) Observing b) Reviewing c) Interviewing d) Examining

44.Occurs when patient responds to questioning. The most productive stage of an interview? a) b) c) d)

Body of the Interview Opening Stage Closing Stage End stage

45.The following are parts of a nursing diagnosis Except: a) Signs and symptoms b) Problem statement c) Presumed etiology d) Assumed statement 46.A deliberative, systematic phase that involves decision making and problem solving. Formulating client goals with the patient. This is what phase? a) Planning phase b) Evaluation phase c) Intervention phase d) Assessment phase

47.Consists of doing and documenting the nursing care given to the patient. Carry out planned activities to help the client. What step in the nursing process is this? a) Implementing phase b) Assessment phase c) Evaluation phase d) Planning phase

48.It is the guidelines for implementation of nursing strategies Except:

a) b) c) d)

It It It It

should should should should

be be be be

based on scientific knowledge adapted to the individual patient based on research, professional standards of practice based on effectiveness of the care plan

49.The main Purpose of the Evaluation Phase are the following except: a) To determine client’s progress b) To determine as to what extent the nursing goals have been met c) To determine if the procedure is still needed d) To determine the effectiveness of the care plan 50.All are requirements in doing implementing phase Except: a) Adequate knowledge b) Technical skills c) Therapeutic use of self d) Determine client’s progress