Using the Nursing Process As Test Item Content Categories

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TEST SHELLS

Using the Nursing Process as Test Item Content Categories

The nursing process can easily be used as a systematic approach to solve problems in individualized nursing care situations. The traditional five-step nursing process consists of assessment, diagnosis, planning, implementation, and evaluation.

MASTER ITEM:
The nurse is (Assessing, Caring, Documenting, Evaluating, Teaching) a Client, who (Client Vignette): (Describe a client with a problem)
Lead-In: Which of the following findings (assessments or manifestations), risks/problems, client goals, drugs, nursing interventions, or evaluation findings?
Options: (List of Assessments, Problems/Risks, Client Goals, Nursing Interventions, and Evaluations)

Nursing Assessment & Collection of Data

The nurse is caring for a client admitted to the hospital, seen in the home/at the clinic] with a medical diagnosis of _____ [Insert diagnosis/disorder].

A.When taking the client’s history, the nurse should expect _____ [her, him] to describe which _____ [complaint, symptom, condition]?

B.When taking the client’s history, which information is most significant?

C.Which question indicates that the nurse understands the major symptoms associated with _____ [Insert diagnosis/disorder]?

D.Which question should the nurse ask the _____ [client, family] (first)?

E.To obtain information needed for _____ {Describe a diagnosis or treatment, etc.}, which question should the nurse ask (first)?

To determine a client’s self-care ability,

A.it is most important for the nurse to ask the _____ [client, family] which question?

B.the nurse should _____ [measure, determine] the client’s ability to perform which activities of daily living?

A client comes to the _____ [clinic, healthcare provider’s office, mental health center, hospital, emergency department] because of _____ [Insert signs and symptoms].

A.Which question is most important for the nurse to ask (first)?

B.Which information is most important for the nurse to obtain (first)?

A _____ [client, family] is scheduled for _____ {Describe a procedure, treatment, therapy, etc.}. Which information is most important to obtain from _____ [him, her, them] _____ [before, after] _____ [the procedure, treatment, therapy, etc.]?

When _____ [auscultating a newborn’s heart rate, talking with the client], it is most important for the nurse to _____ [implement which intervention, ask which question]?

. Which information relates most directly to a diagnosis of _____ [Insert disease/disorder]?

Which environmental factors are most disturbing to a client with _____ [Insert diagnosis/disorder]?

Which symptom is the client with _____ [Insert disease/disorder] most likely to exhibit _____ [upon admission to the hospital, within the first 24 hours after admission to the hospital]?

Which symptom most clearly relates to _____ {Describe a condition, medical diagnosis, etc.}?

Which symptom(s) is (are) most characteristic of _____ [Insert diagnosis/disorder]?

The nurse observes a client for signs of _____ [Insert disease/disorder], which are most likely to include which [symptom, condition, complaint]?

When observing a client for symptoms of _____ [Insert disease/disorder], [the nurse should assess, it is most important that the nurse to assess] for which _____ [finding, condition]. {Make distracters discriminating.}

To determine _____ [status or seriousness of complaint],

A.the nurse should _____ [assess for which condition, ask which question]?

B.what question is most important for the nurse to ask (first)?

C.which information is most important for the nurse to obtain?

Which approach is best for the nurse to use when assessing _____ [for the presence of uterine contractions, a client’s risk for attempting suicide]?

In caring for a client with _____ [Insert disease/disorder], the nurse should be alert for which complication?

When assessing a client, which _____ [blood value, behavior] indicates that the client is experiencing normal changes associated with _____ [pregnancy, adolescence]?

A client comes to the emergency department with _____ [symptoms of placenta previa/abruption, increased intracranial pressure]. {Instead of naming a disorder, a description of symptoms could also be used.}

A.What _____ [data, information, lab finding] should the nurse obtain (first)?

B.What assessment data are most important for the nurse to obtain (first)?

C.What information is most important to obtain in determining the client’s _____ [prognosis, immediate nursing care]?

The nurse anticipates _____ [the baby of a mother who had a high alcohol intake during pregnancy, the child of an alcoholic] to exhibit which _____ [symptoms, behaviors] during _____ [the first day of life, adolescence]?

Because of the inability to _____ [conceive, walk], the nurse should assess this client’s history for which _____ [condition, factors]?

When performing an initial _____ [post delivery, postoperative] assessment, the nurse should expect the client’s _____ [lochia, bandage, urine] to have which appearance?

A [client, couple] with _____ [late stage ovarian cancer, known fertility problems] is most likely to exhibit which behavior?

Which member of the staff should the nurse assign to assess a client with _____ [Insert disease/disorder]

Which information is most important for the nurse to obtain from the family of a woman who _____ [recently attempted suicide, has just been told she has inoperable cancer]?

ConfirmData

When observing a client for symptoms of _____ [shock, increased intracranial pressure], the earliest symptom of this condition can be obtained by which _____ [measurement, assessment]?

Prior to administration of each dose of _____ [insert drug name and proprietary name], it is most important for the nurse to obtain which assessment?

{Describe a medication or treatment.} is prescribed for a client with _____ {Describe a medical diagnosis, symptoms, certain laboratory findings.}. Which conclusion regarding this _____ [medication, treatment] is accurate?

[Insert drug] is prescribed for a child weighing _____, and the normal dosage is _____/kg. What dosage of the [Insert drug] should the nurse administer?

The nurse is correct to question which activity of a client with _____ [Insert disease/disorder]?

{Describe a reading from a medical equipment device or a finding that indicates that a medical equipment device is malfunctioning.}. When encountering a strange reading from a _____ [respirator, fetal monitor], what action should the nurse take (first)?

Communicate Information Gained in Assessment

Which information should the nurse communicate immediately to the _____ [healthcare provider, charge nurse, family, and client]?

Which group of symptoms should be reported to the _____ [healthcare provider, social worker]?

A client is scheduled to have _____ [an ultrasound, endoscopy, heart catheterization]. Which information is most important to obtain _____ [before, during, after] the procedure?

Identification of NEEDS/Problems

Identify Actual or Potential Healthcare Needs/Problems Based on Assessment

Interpret Data

The _____ [physician, healthcare provider] prescribes _____ {Describe a medication or treatment.}. Before _____ [transcribing the prescription, initiating the treatment], it is most important for the nurse to implement which intervention?

Two hours after _____ [delivery, surgery], the _____ [infant, child, and client] is lethargic and has developed _____ [mild generalized cyanosis, a low blood pressure]. The nurse recognizes that the _____ [infant, child client] is most likely exhibiting symptoms of which condition?

{Describe an assessment finding such as heart rate, temperature, etc.}

A.Why should the nurse notify the _____ [physician, healthcare provider]?

B.What action should the nurse take (first)?

C.Based on this information, which intervention should the nurse include in the client’s plan of care?

A [woman, adolescent] gained _____ {Insert number.} pounds at _____ [8 weeks gestation, 13 years of age]. According to expected weight gain for this _____ [gestation, age child], which interpretation by the nurse is accurate?

A client is admitted with a diagnosis of _____ [Insert diagnosis/disorder]. This condition is

A.most often manifested by which _____ [symptom, finding, condition]?

B.primarily due to which _____ [condition, environmental hazard]?

C.most often exacerbated by which _____ [environmental condition, health-related behavior]?

The nurse is assessing a _____ [gravida 5, three days postoperative] client who is complaining of _____ [intermittent uterine cramping, nausea]. These complaints are most likely due to which condition?

The nurse is assessing _____ [a client, child, or an infant] whose _____ [Insert affected vital signs, laboratories or manifestations].

A.The _____ [respiratory rate, hematocrit] is most likely due to which _____ [condition, finding]?

B.The _____ [client, infant] is exhibiting which _____ [condition, potential problem, health-related behavior]?

The _____ {Describe the client’s condition, medical diagnosis, etc.} client received _____ [a bolus anesthetic via epidural catheter before delivery, 10 mg morphine sulfate IV push in the emergency department].

A.It is essential for the nurse to consider which aspect of this client’s care?

B.It is most important for the nurse to collect which information prior to administration?

A client’s susceptibility to _____ [infection] is most likely

A.due to which aspect in the client’s history?

B.related to a history of which condition?

C.due to which environmental factor?

Based on the nurse’s assessment of a _____ [postpartum, postoperative] client, which finding indicates _____ [the presence of an abnormality, a normal test result]?

The nurse is caring for a _____ [postpartum, postoperative] client who has a prescription for _____ {Describe a medication or treatment regime.}. What is the main purpose of this _____ [medication, treatment regime]?

Which characteristic of a _____ [newborn, 5-year-old] should the nurse consider _____ [a normal, an abnormal] finding?

When monitoring a client’s respiratory status,

A.which symptom provides the nurse with the earliest indication of respiratory difficulty?

B.which finding should be reported to the _____ [physician, healthcare provider] immediately?

C.the nurse should interpret which finding as within normal limits for a client with _____ [COPD, chronic bronchitis]?

The client had _____ [epidural anesthesia, an endoscopic procedure], which condition should the nurse anticipate as a potential problem?

Formulate Nursing Diagnoses

{Describe assessment data.} Based on these data,

A.which nursing diagnosis should the nurse document for this client?

B.what is the priority nursing diagnosis for this client?

C.this client’s symptoms are most clearly an example of which _____ [condition, problem]?

As the result of a client _____ [smoking 2 packs of cigarettes a day, using cocaine] during _____ [pregnancy, their adult life], the _____ [fetus, client] is at greatest risk for developing which _____ [condition, disease]?

A client who is 6 hours _____ [postpartum, postoperative] is having difficulty voiding. The nurse identifies a nursing diagnosis of “impaired urinary elimination” that is secondary to which condition?

The nurse recognizes which factor in the client’s history is

A.most likely to be related to a diagnosis of _____ [INSERT DIAGNOSIS/DISORDER]?

B.the most important etiological factor in developing _____ [INSERT DIAGNOSIS/DISORDER]?

Which finding is indicative of a nursing diagnosis of _____ [decreased cardiac output, anxiety related to...]?

_____ {Describe a medication or treatment.} is most often used for _____ [postpartum, postoperative] clients with _____ [diabetes, myasthenia gravis] because of _____ [its action on which organ, the low incidence of which side effect]?

The method used to treat _____ [hypertension, arthritis] is based chiefly upon its _____ [action on which organ, ability to treat which condition]?

Communicate Results of Analysis

The nurse understands that the main purpose of the _____ [Apgar score, Glasgow Coma Scale] is to describe which _____ [parameter, condition]?

A client is to receive _____ {Describe a medication or treatment, etc.} for _____ [Insert diagnosis/disorder].

A.Which finding, if present, should the nurse report to the _____ [physician, healthcare provider] before administering the _____ [medication, treatment]?

B.After administering the _____ [medication, treatment], which assessment finding should the nurse document?

The nurse cautions a client who _____ [is taking a drug, or having a particular manifestation] to _____ [avoid sunlight, eat small, frequent meals]. Why is this instruction important?

Planning Of Care

Setting Goals for Meeting Client’s Needsand Designing Strategies to Achieve These Goals

Prioritize Nursing Diagnoses

When planning care for a client with [Insert diagnosis/disorder],

A.which nursing diagnosis has the highest priority?

B.which nursing diagnosis should the nurse plan to address first?

A client is seen in the _____ [clinic, hospital, emergency room] with _____ [an increased blood pressure, an elevated temperature, pinpoint pupils]. Which nursing diagnosis has the highest priority?

Initial treatment for a client with _____ [Insert diagnosis/disorder] should be based on which nursing diagnosis?

Determine Goals of Care

What is the most important goal of care for the client who is receiving _____ {Describe a medication, treatment, etc.}?

Which assessment should the nurse plan to obtain after a client has received a prescription for _____ [an antihypertensive drug, a central nervous system depressant] to treat _____ [Insert diagnosis/disorder]?

On admission to _____ [the hospital/clinic, labor and delivery] a client reports having _____ [a headache for the past two days, epigastric pain]. The nurse should give the highest priority to which goal?

When preparing the care plan for a client _____ [with PIH, who has recently attempted suicide], it is most important for the nurse to include a goal that addresses which need?

Formulate Outcome Criteria for Goals of Care

A client has _____ [Insert diagnosis/disorder]. Which [long-term, short-term] outcome is most important

A.for the nurse to consider?

B.for this client?

C.in planning this client’s care?

Upon admission, the nurse should give the highest priority to meeting which need of a client who _____ [recently aborted an 18-week fetus, is brought to the emergency room unconscious]?

Develop a Plan of Care and Modify as Necessary

A client with a [positive RPR, An HIV positive client] is seen in the clinic for follow-up care. Which nursing intervention is most essential to include in this client’s plan of care?

In planning a _____ [1,500 calorie diabetic, a low-residue] diet for a client who _____ [was recently diagnosed as diabetic, is scheduled for abdominal surgery], the nurse should ask the client if they would like to have which _____ [food, snack, dessert]?

When preparing for _____ {Describe a procedure, treatment, etc.}, the nurse should _____ [provide the client/family with which instruction, review which laboratory finding]?

What instruction should the nurse include in the discharge teaching plan of a client who _____ [was recently diagnosed with diabetes, had a right cataract extraction]?

As a result of the client’s positive _____ [lab test for STD, infectious disease] culture, the nurse should prepare the client for which treatment?

Because of the mother’s history of _____ [cocaine use, smoking 2 packs of cigarettes a day,] the nurse should expect the infant to exhibit which behavior?

Which intervention should the nurse plan to implement to reduce a client’s discomfort during _____ [labor, a bone marrow aspiration]?

To prevent _____ [increased intracranial pressure, hemorrhage], which intervention should the nurse include in a client’s plan of care?

The nurse is caring for a client with _____ [an abdominal incision, a stoma].

A.Which intervention is most important to include in this client’s plan of care?

B.Which nursing intervention has the greatest priority when planning this client’s care?

When preparing a client for _____ [an amniocentesis, surgery], it is essential for the nurse to take which action?

{Describe a situation that involves initiating an IV infusion pump.} The nurse should set the pump to deliver how many ml per hour? {This could be a fill-in-the-blank test item.}

Hint: Math test items that require rounding should conclude with a rounding instruction such as If rounding is required, round to the nearest tenths, or If rounding is needed, round to one decimal place/two decimal places/whole number. Fill-in-the-blank math test items should conclude with an instruction such as Enter numerical value only. These instructions are usually placed in parentheses at the end of the test item stem.

Which room is best for the nurse to assign a client _____ [who is exhibiting signs of depression, with PIH]?

It is important for the nurse to ensure that a client with _____ [Insert diagnosis/disorder] has a room that _____ [is in which location, has which feature(s)]?

Collaborate with Other Healthcare Team Members When Planning Delivery of Care

A client is being discharged from the hospital with _____ {Describe equipment, medication, etc.}. When planning this client’s discharge, it is most important for the nurse to

A.coordinate with which member of the healthcare team?

B.include a referral to which agency?

Assessment findings reveal that a client is _____ [afraid of dying, in need of financial assistance]. Which healthcare team member is likely to be most helpful in planning this client’s care?

When assigning care of _____ [an older adult, an adolescent], which healthcare team member is best to provide care for this client?

Communicate Plan of Care

When teaching a _____ client [insert disease/disorder e.g. diabetic client, client who had a myocardial infarction],

A.it is important for the nurse to focus on which aspect of home care?

B.which instruction is most important for the nurse to include in this client’s discharge teaching plan?

A _____ [couple, client] who is unable to _____ [conceive, self-administer insulin] asks the nurse _____ [what could be wrong, to tell him what he is doing wrong]. Which information should be included in the nurse’s explanation to this couple/client?

Implementation of Care

Initiate and Complete Actions Necessaryto Accomplish Defined Goals

Organize and Manage Client’s Care

A client who is 12 hours _____ [postpartum, postoperative] begins to have difficulty breathing and complains of acute chest pain. What action should the nurse take first?

After _____ [administering oxygen to a newborn, raising the head of the bed for a client who is having difficulty breathing], the nurse should implement which intervention?

The nurse provides _____ {Describe a treatment or intervention.} for a _____ [client, newborn]. To achieve the desired outcome of this procedure, which nursing action

A.should be taken/done first?

B.has the highest priority?

. A client was in a _____ [describe a position e.g. lithotomy, supine] position for two hours during _____ [transition and vaginal delivery, a surgical procedure].

A.The nurse should perform which intervention during the _____ [early postpartum period, immediate postoperative period]?

B.Which nursing intervention is most helpful to this client during the _____ [early postpartum period, immediate postoperative period]?

When developing a plan of care for _____ [a premature infant, an adolescent who is addicted to cocaine], the nurse recognizes that it is essential to consider which _____ [assessment finding, factor in the client’s family history]?