Fundamentals of Nursing Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. The nurse is utilizing assessment data to analyze and interpret the information to develop a nursing diagnosis. This involves critical thinking skills to make conclusions and create a plan of care. A: Assigning clinical cues - This choice is incorrect as it refers to identifying objective and subjective data during assessment, not the process of analyzing and synthesizing data to form a diagnosis. B: Defining characteristics - This choice is incorrect as it typically refers to the specific manifestations or symptoms associated with a particular nursing diagnosis, not the process of diagnosing itself. D: Diagnostic labeling - This choice is incorrect as it refers to the final step in the nursing diagnosis process where the nurse assigns a label to the identified problem, not the overall process of diagnostic reasoning.

Correct Answer: C

Rationale: The correct answer is C because performing a physical examination is the method nurses use to establish a patient's database. This involves directly assessing the patient's physical condition, gathering data on their health status, and identifying any abnormalities or concerns. Reviewing literature (A) is important but not a direct method of collecting patient data. Checking orders for tests (B) is part of data collection but not the initial step. Ordering medications (D) is a treatment action, not data collection.

Correct Answer: B

Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease. Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI). Step 3: Age is a risk factor for CAD but not directly linked to MI development. Step 4: Medication usage may impact risk factors but is not a direct cause of MI. Step 5: Gender can influence risk but is not the primary factor in MI development.

Correct Answer: B

Rationale: The correct answer is B because during outcome identification and planning, it is crucial to prioritize problems that require immediate attention to ensure patient safety and well-being. By asking what problems need immediate attention, nurses can focus on addressing urgent issues first. Choice A focuses on data clustering for problem identification, choice C is related to defining characteristics for nursing diagnoses, and choice D pertains to documentation, which are important but not directly related to prioritizing immediate problems.

Correct Answer:

Rationale: Correct Answer: A: The patient will ambulate in the hallway twice this shift using crutches correctly. Rationale: 1. This choice outlines a specific nursing intervention - ambulating with crutches. 2. It includes clear actions for the patient to ambulate and specifies using crutches correctly. 3. It addresses the patient's physical mobility needs actively. 4. It focuses on promoting independence and functional ability. Summary of other choices: B: This choice includes the nursing diagnosis and the plan but lacks the specificity of the correct answer. C: This choice includes the nursing diagnosis and specifies the use of crutches but lacks the clarity of correct implementation. D: This choice only identifies the patient's condition without providing a specific nursing intervention.