Nursing 104

N104 Study Guide

Answer Keys

Chapter 1 1. D - The nursing process involves planning care for any patient in any environment. As the nurse evaluates progress towards outcomes, she will begin the process of assessment again. 2. C - These are the steps of the nursing process that are typically followed when planning and delivering care. 3. B - A complete health history and physical assessment is done in a comprehensive assessment. Collection of baseline data may be part of a focused assessment, but the purpose of a focused assessment is to do the assessment with focus on the particular need that is currently identified. 4. C - The nursing process must be a patient-centered process. The needs of the nurse and physician are not part of the process. The needs of the family are secondary. 5. B - Since the patient is describing his symptoms, this is primary source subjective. If the nurse examines the patient's throat and it is red, the nurse's findings would be primary source objective (something that can be seen). Secondary sources are any other sources other than the patient. 6. A - These are the commonly recognized stages of needs. The theory is that the most basic needs must be met before addressing higher level needs. 7. B - During planning, the nurse and patient collaborate to develop the problem list, nursing diagnoses, goals, and outcomes. Nurses do not develop medical diagnoses. 8. D - As long as a task is within an individual's scope of practice, the nurse may delegate the task to another individual. Some interventions do require a physician's order (dependent), but many can be done without an order (independent). The patient’s response to treatment must always be the primary consideration when evaluating the effectiveness of an intervention. 9. D - Any of these options may be a reason that an outcome is not met. 10. A - Before any changes are made, the nurse should follow the nursing process and reassess the patient. Any or all of the other options may ultimately be done, but they should all be preceded by an assessment of the patient's abilities.

©2018

Achieve

Page 127

of 134