ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 5 : Nursing Process and Critical Thinking Questions
Question 1 of 5
The nurse writes two patient problems: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses?
Correct Answer: D
Rationale: The actual patient problem represents a condition that is currently present. 'Risk for' diagnoses are those that the patient is susceptible to, but not yet troubled by.
Question 2 of 5
What framework does the establishment of priorities of care during the planning phase of the nursing process often use?
Correct Answer: C
Rationale: A useful framework to guide prioritization is Maslow's hierarchy of needs.
Question 3 of 5
What is an appropriate outcome statement for a patient with a patient problem of ineffective airway clearance related to thick secretions?
Correct Answer: A
Rationale: The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within 3 days is too vague.
Question 4 of 5
What is the primary purpose of nursing interventions?
Correct Answer: B
Rationale: Nursing orders are necessary to provide instructions for all caregivers.
Question 5 of 5
What documentation reflects implementation?
Correct Answer: C
Rationale: Implementation is the nurse carrying out nursing orders to promote outcome achievement.