The Nursing Process (part 3)

Question 1

The nurse is most likely to collect timely, specific information by asking which of the following questions?

A. “Would you describe what you are feeling?”
B. “How are you today?”
C. “What would you like to talk about?”
D. “Where does it hurt?”

Answer 1

A. “Would you describe what you are feeling?”

Rationale: This is an open-ended question that will elicit subjective data. The data collected will reflect the client’s current health status and human response(s) and should generate specific information that can be used to identify actual and/or potential health problems. Options 2 and 3 are more likely to elicit general, nonspecific information. Option 4 may result in a brief, one-word response or nonverbal gesture indicating the site of the client’s pain. A better approach to collect specific information might be, “Describe any pain you are having.”

Question 2

The nurse should avoid asking the client which of the following leading questions during a client interview?

A. “What medication do you take at home?”
B. “You are really excited about the plastic surgery, aren’t you?”
C. “Were you aware I’ve has this same type of surgery?”
D. “What would you like to talk about?”

Answer 2

B. “You are really excited about the plastic surgery, aren’t you?”

Rationale: A leading question directs the client’s answer. The phrasing of the question indicates an expected answer. The client may be influenced by the nurse’s expectations and may give inaccurate responses. This process can result in an error in diagnostic reasoning.

Question 3

The nurse needs to validate which of the following statements pertaining to an assigned client?

A. The client has a hard, raised, red lesion on his right hand.
B. A weight of 185 lbs. is recorded in the chart
C. The client reported an infected toe
D. The client’s blood pressure is 124/70. It was 118/68 yesterday.

Answer 3

C. The client reported an infected tow

Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse should assess the client’s toe to validate the statement.

Question 4

Which of the following items of subjective client data would be documented in the medical record by the nurse?

A. Client’s face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feel nauseated

Answer 4

D. Client feel nauseated

Rationale: Subjective data includes the client’s sensations, feelings, and perception of health status. Subjective data can only be verified by the affected person. Options 1, 2, and 3 represent objective data that can be detected by the nurse or measured against an accepted norm.

Question 5

A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift?

A. Nurse and client agree upon health care goals for the client
B. Nurse reviews the client’s history on the medical record
C. Nurse explains to the client the purpose of each administered medication
D. Nurse rapidly reset priorities for client care based on a change in the client’s condition

Answer 5

D. Nurse rapidly reset priorities for client care based on a change in the client’s condition

Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process.

Question 6

The client reports nausea and constipation. Which of the following would be the priority nursing action?

A. Collect a stool sample
B. Complete an abnormal assessment
C. Administer an anti-nausea medication
D. Notify the physician

Answer 6

B. Complete an Abdominal assessment

Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client’s complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client’s care. The other options reflect interventions, which are not timely unless there is first a complete assessment.

Question 7

The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following?

A. Incomplete data
B. Generalize from experience
C. Identifying with the client
D. Lack of clinical experience

Answer 7

A. Incomplete data

Rationale: To collect data accurately, the client must actively participate. Incomplete data can lead to inappropriate nursing diagnosis and planning. The other options are not relevant to the question as presented.

Question 8

The nurse notes that the client often sighs and says in a monotone voice, “I’m never going to get over this.” When encouraged to participate in care, the client says, “I don’t have the energy.” The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply.

A. Hopelessness
B. Powerlessness
C. Interrupted sleep pattern
D. Disturbed self esteem
E. Self care deficit

Answer 8

A. Hopelessness
B. Powerlessness

Rationale: Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5).

Question 9

Which of the following descriptors is most appropriate to use when stating the “problem” part of a nursing diagnosis?

A. Grimacing
B. Anxiety
C. Oxygenation saturation 93%
D. Output 500 mL in 8 hours

Answer 9

B. Anxiety

Rationale: The problem part of a nursing diagnosis should state the client’s response to a life process, event, or stressor. These are categorized as nursing diagnoses. The incorrect options are cues the nurse would use to formulate the nursing diagnostic statement.

Question 10

Which desired outcome written by the nurse is correctly written and measurable?

A. Client will have a normal bowel pattern by April 2
B. The client will lose 4 lbs. within next 2 weeks
C. The nurse will provide skin care at least 3 times each day
D. The client will breathe better after resting for 10 minutes

Answer 10

B. The client will lose 4 lbs. within next 2 weeks

Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Each of the incorrect options lacks one of these required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a client goal. Option 4 does not include the level at which the behavior should be performed.

Question 11

The rehabilitation nurse wishes to make the following entry into a client’s plan of care: “Client will reestablish a pattern of daily bowel movements without straining within two months.” The nurse would write this statement under which section of the plan of care?

A. Nursing diagnosis/problem list
B. Nursing orders
C. Short-term goals
D. Long-term goals

Answer 11

D. Long-term goals

Rationale: Long-term goals describe changes in client behavior expected over a time frame greater than one week. They are usually designed to restore normal functioning in a problem area and are helpful to other healthcare workers who care for the client, often in a variety of settings.

Question 12

Which of these is a correctly stated outcome goal written by the nurse?

A. The client will walk 2 miles daily by March 19
B. The client will understand how to give insulin by discharge
C. The client will regain their former state of health by April 1
D. The client achieve desired mobility by May 7

Answer 12

A. The client will walk 2 miles daily by March 19

Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option 1 is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19).

Question 13

The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?

A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness during hospital stay
C. Client will state pain relieved within 30 minutes after medication
D. Pressure will be prevented by repositioning client every 2 hours

Answer 13

B. Skin will remain intact and without redness during hospital stay

Rationale: The human response/label is what needs to change (Risk for impaired skin integrity). The label suggests the outcomes. In this case, “skin will remain intact” is the desired outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility. Option 3 addresses pain. Option 4 is an intervention.

Question 14

While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?

A. Help client into the chair but more quickly
B. Document client’s vital signs taken just prior to moving the client
C. Help client back to bed immediately
D. Observe client’s skin color and take another set of vital signs

Answer 14

D. Observe client’s skin color and take another set of vital signs

Rationale: Assessment is ongoing throughout the nurse-client relationship. During re-assessment, the nurse collects additional data to help evaluate the status of problems or identify new problems. Options 1, 2, and 3 are interventions.

Question 15

After instructing the client on crutch walking technique, the nurse should evaluate the client’s understanding by using which of the following methods?

A. Return demonstration
B. Explanation
C. Achievement of 90 on written test
D. Have client explain produce to the family

Answer 15

A. Return demonstration

Rationale: Interpersonal skills are the sum of the activities the nurse uses when communicating with others. Technical/psychomotor skills are “hands-on” skills, which are often procedures and are evaluated by return demonstration. Cognitive skills are the intellectual skills of analysis and problem-solving and are evaluated by tests.

Question 16

The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult?

A. Formulate a nursing diagnosis of impaired gas exchange
B. Record in the medical record the distance a client ambulate in the hall
C. Write individualized nursing orders in the care plan
D. Compare client responses to the desired outcomes for pain relief

Answer 16

B. Record in the medical record the distance a client ambulate in the hall

Rationale: The implementation phase of the nursing process involves carrying out or delegating the nursing interventions and recording nursing activities and client responses in the medical records. Option 1 represents diagnosing. Option 3 represents planning. Option 4 represents evaluation.

Question 17

A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, “I’m tired of being sick. I wish I could end it all.” What is the most accurate and informative way to record this data in a nursing progress note?

A. Client appears to be depressed, possibly suicidal
B. Client reports being tired of being ill and wants to die
C. Client does not want to live any longer and is tired of being ill
D. Client states, “I’m tired of being sick. I wish I could end it all.”

Answer 17

D. Client states, “I’m tired of being sick. I wish I could end it all.”

Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client’s exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

Question 18

The nurse evaluates the client’s progress and determines that one of the nursing diagnoses on the client’s care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?

A. Use Liquid PaperTM to “white out” the resolve diagnosis on the care plan
B. Recopy the care plan without the resolve diagnosis
C. Write a nursing process not indicating that the outcome goals have been achieved
D. Draw a single line through the diagnosis on the care plan and write the nurse’s initials and date

Answer 18

D. Draw a single line through the diagnosis on the care plan and write the nurse’s initials and date

Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a “Date Resolved” column. Using Liquid PaperTM is not a legal way to amend client records. Outcome goals that have been met and nursing diagnoses that have been resolved should be documented on the care plan. A progress note should also be written, but a single note may not be read by all health team members.

Question 19

The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client’s outcome goals that were met and those that were not. To do this effectively, the nurse should:

A. Formulate post-discharge nursing diagnoses
B. Draw conclusion about resolution of current client problems
C. Assess the client for baseline data to be used at the LTC facility
D. Plan the care that is needed in the LTC facility

Answer 19

B. Draw conclusion about resolution of current client problems

Rationale: Terminal evaluation is done to determine the client’s condition at the time of discharge. This evaluation is best reflected in option 2 because it focuses on which goals were achieved and which were not. Ongoing evaluation is done while or immediately after implementing a nursing intervention. Intermittent evaluation is performed at specified intervals, such as twice a week. Items related to care post-discharge (options 2, 3, and 4) should be done on admission to the LTC facility.

Question 20

A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?

A. Help the client to get settled and do the interview the next morning when the client is rested
B. Do the interview immediately, directing the majority of the questions to the client’s spouse
C. Do the interview as soon as some uninterrupted time is available in order to address the client’s concerns
D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication

Answer 20

C. Do the interview as soon as some uninterrupted time is available in order to address the client’s concerns

Rationale: To collect data accurately, the client must participate. Attending to the client’s immediate personal needs before expecting the client to focus on the interview will maximize the accuracy of the data collected. Data should be collected shortly after admission. The best source of data is the client. The management of the client’s anxiety is the responsibility of the nurse conducting the interview and initiating the relationship.

Question 21

The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply.

A. Collect and organize client information
B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses
E. Develop client goals

Answer 21

B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses

Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase.

Question 22

The functional health pattern assessment data states: “Eats three meals a day and is of normal weight for height.” The nurse should draw which of the following conclusions about this data? Select all that apply.

A. Client has an actual health problem
B. Client has a wellness diagnosis
C. Collaborative health problem needs to be written
D. Possible nursing diagnosis exists
E. Specific questions about the diet should be asked next

Answer 22

B. Client has a wellness diagnosis
E. Specific questions about the diet should be asked next

Rationale: The description indicates a healthy pattern of nutrition for the client. A wellness diagnosis might be stated as: “Potential for enhanced nutrition.” An actual health problem is a client problem that is currently present. The nurse should also do a diet assessment to determine the quality of the food eaten during meals. These actions by the nurse are within the scope of independent nursing practice and are not collaborative in nature.

Question 23

For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?

A. Discomfort
B. Deficit
C. Feeding
D. Fractured wrists

Answer 23

D. Fractured Wrists

Rationale: The etiology or related factors of a nursing diagnostic statement define one or more probable causes of the problem and allow the nurse to individualize the client’s care. In this case, the fracture is the cause of the client’s feeding problem.

Question 24

The nurse would make which of the following inferences after performing the appropriate client assessment?

A. Client is hypotensive
B. Respiratory rate of 20 breaths per minute
C. Oxygen saturation of 95%
D. Client relays anxiety about blood work

Answer 24

A. Client is hypotensive

Rationale: An inference is the nurse’s judgment or interpretation of cues such as judging a blood pressure to be lower than normal. A cue is any piece of data information that influences a decision. Options 2, 3, and 4 are cues that could lead to inferences.

Question 25

The nurse would write which of the following outcome statements for a client starting an exercise program?

A. Client will walk quickly three times a day
B. Client will be able to walk a mile
C. Client will have no alteration in breathing during the walk
D. Client will progress to walking a 20-minute mile in one month

Answer 25

D. Client will progress to walking a 20-minute mile in one month

Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. They should also be realistic and achievable.

Question 26

The nurse decides it would be beneficial to the client to allow the client’s infant granddaughter to visit before the client’s scheduled heart transplant. Before implementing this intervention the nurse should collaborate with which of the following? Select all that apply.

A. Client and Family
B. Other nursing staff on the unit
C. Security department
D. Hospital administration
E. This is not a collaborative intervention so no collaboration will be needed prior to implementation

Answer 26

A. Client and Family
B. Other nursing staff on the unit

Rationale: Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it.

Question 27

The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time?

A. Assessment
B. Planning
C. Implementation
D. Evaluation

Answer 27

C. Implementation

Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client’s safety. This action represents the implementation phase of the nursing process. Data gathering occurs during assessment. Goal setting occurs during planning. Determining attainment of client goals occurs as part of evaluation.

Question 28

A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client’s progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write?

A. Client understands the signs of impaired circulation
B. Goal met: Client cited numbness and tingling as sign of impaired circulation
C. Goal not met: Client able to name only two signs of impaired circulation
D. Goal not met: Client unable to describe signs of impaired circulation

Answer 28

C. Goal not met: Client able to name only two signs of impaired circulation

Rationale: The goal has not been met because the client states only two out of three signs of impaired circulation. By comparing the data with the expected outcomes, the nurse judges that while there has been progress toward the goal, it has not been completely met. The care plan may need to be revised or more effective teaching strategies may need to be implemented to achieve the goal.