Which statement best defines the nursing process? Select one answer

Series of assessments that isolate a client’s health problem

Framework for the organization of individualized nursing care

Preset formula for the design of nursing care

Method to assure that the physician’s orders are carried out correctly

Answer and Explanation

The Correct Answer is B

Choice A reason: Series of assessments that isolate a client’s health problem is not the best definition of the nursing process. The nursing process is not only a series of assessments, but also a series of actions that include planning, implementing, and evaluating the nursing care. The nursing process does not isolate a client’s health problem, but rather identifies and addresses the client’s holistic needs and responses to health and illness. Therefore, this choice is incorrect.

Choice B reason: Framework for the organization of individualized nursing care is the best definition of the nursing process. The nursing process is a framework that guides the nurse’s decision making and actions in providing individualized nursing care to each client. It involves five steps: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. It is based on scientific principles, ethical standards, and evidence-based practice. Therefore, this choice is correct.

Choice C reason: Preset formula for the design of nursing care is not the best definition of the nursing process. The nursing process is not a preset formula, but rather a dynamic and ﬂexible method that adapts to the changing needs and situations of each client. It requires critical thinking, creativity, and clinical judgment from the nurse. It also involves collaboration and communication with the client and other members of the health care team. Therefore, this choice is incorrect.

Choice D reason: Method to assure that the physician’s orders are carried out correctly is not the best definition of the nursing process. The nursing process is not a method to assure that the physician’s orders are carried out correctly, but rather a method to provide independent and autonomous nursing care that complements or supplements the medical care. The nursing process reﬂects the nurse’s scope of practice, responsibility, and accountability for the client’s well-being. It also empowers the client to participate in their own care and achieve their health goals. Therefore, this choice is incorrect.

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Correct Answer is A

Explanation

Choice A reason: “I can see you are worried.” is a therapeutic response by the PN to the family at this time. This response shows empathy, which is the ability to understand and share the feelings of another person. It also acknowledges and validates the family’s emotions, and invites them to express their concerns or fears. Therefore, this choice is correct.

Choice B reason: “Don’t worry, you have nothing to feel guilty about.” is not a therapeutic response by the PN to the family at this time. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also implies that the family should feel guilty, and denies them the opportunity to explore their feelings or thoughts. Therefore, this choice is incorrect.

Choice C reason: “Everything possible is being done.” is not a therapeutic response by the PN to the family at this time. This response shows cliché, which is a communication technique that involves using overused or trite expressions that lack meaning or sincerity. It also avoids addressing the family’s emotions or needs, and may sound vague or insincere. Therefore, this choice is incorrect.

Choice D reason: “Let me check if you can see your loved one.” is not a therapeutic response by the PN to the family at this time. This response shows changing the subject, which is a communication technique that involves shifting the focus away from the other person’s feelings or situation. It also ignores or postpones the family’s emotional needs, and may make them feel unimportant or dismissed. Therefore, this choice is incorrect.

A. Identifying one way to increase social interaction B. Returning a demonstration of measures that can increase independence C. Identifying at least one factor contributing to altered sexuality paterns D. Reporting increased adaptation to changes in health status

Correct Answer is D

Explanation

Choice A reason: Symptoms are subjective data that are reported by the client, such as pain, nausea, or fatigue. They are not observable or measurable by the nurse, and they may vary depending on the client’s perception or expression. The data that the PN discovered are not symptoms, but objective data that are observed or measured by the nurse, such as skin condition, oral mucus membranes, and temperature. Therefore, this choice is incorrect.

Choice B reason: Urinary retention is a condition in which the client is unable to empty the bladder completely or at all. It can cause symptoms such as difficulty or pain in urinating, frequent or urgent urination, or abdominal distension. It can also lead to complications such as infection, kidney damage, or bladder rupture. The data that the PN discovered are not related to urinary retention, but to dehydration or fever. Therefore, this choice is incorrect.

Choice C reason: Signs of ﬂuid overload are objective data that indicate excess ﬂuid in the body, such as edema, weight gain, crackles in the lungs, or elevated blood pressure. They can result from conditions such as heart failure,

kidney failure, or liver cirrhosis. The data that the PN discovered are not signs of ﬂuid overload, but signs of ﬂuid deficit or heat stroke. Therefore, this choice is incorrect.

Choice D reason: Data clustering is a process of grouping related data together to form a meaningful patern that can support a nursing diagnosis. It can help the nurse to identify the client’s problems, needs, or risks, and to prioritize and plan interventions accordingly. The data that the PN discovered are an example of data clustering, as they represent a patern of signs that indicate a possible problem such as dehydration or fever. Therefore, this choice is correct.

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Which statement best defines the nursing process? Select one answer

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Family members awaiting the outcome of a suicide atempt are tearful. Which response by the Practical Nurse (PN) is therapeutic to the family at this time? * Select one answer

Correct Answer is A

Explanation

Correct Answer is D

Explanation

A client of the Islamic faith refuses to eat a hot dog on his tray because he is afraid that it may contain pork products. Which of the following is the best response by the Practical Nurse (PN)?

A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

What should the nurse do with linens that have been soiled by a client with hepatitis?

The young client says, “I’m really stressed out about this pregnancy.” When the Practical Nurse (PN) responds, “What about this pregnancy worries you?”, he or she is using the technique of:

A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client’s leg is pain free, without redness or edema. The nurse’s actions reﬂect which phase of the nursing process? Select one answer

During the planning step of the nursing process, the nurse performs which activity? Select one answer

The husband of a client who has a Sengstaken-Blakemore tube states to the nurse, “I thought having this tube down her nose the first time would convince my wife to quit drinking.” The nurse should make which response to the client’s husband? Select one answer

A Practical Nurse (PN) is planning on leaving the room of a patient with a tracheotomy. The PN ensures that the client has which of the following means of communication before leaving the room?