NURSING PROCESS QUESTIONS-NUR
102 QUESTIONS AND CORRECT
ANSWERS
TheA2nurseA2inA2chargeA2identifiesA2aA2patient'sA2responsesA2toA2actualA2orA2potentialA2he
althA2problemsA2duringA2whichA2stepA2ofA2theA2nursingA2process?A2-A2Ans--
Diagnosis:A2TheA2nurseA2identifiesA2humanA2responsesA2toA2actualA2orA2potentialA2healthA
2problemsA2duringA2theA2nursingA2diagnosesA2stepA2ofA2theA2nursingA2process.A2DuringA2t
heA2assessmentA2step,A2theA2nurseA2collectsA2data.A2DuringA2theA2planningA2step,A2theA2n
urseA2developsA2strategiesA2toA2resolveA2orA2decreaseA2theA2patient'sA2problem.A2DuringA
2evaluation,A2theA2nurseA2determinesA2theA2effectivenessA2ofA2theA2planA2ofA2care
AA2femaleA2patientA2isA2diagnosedA2withA2deep-
veinA2thrombosis.A2WhichA2nursingA2diagnosisA2shouldA2receiveA2theA2highestA2priorityA2a
tA2thisA2time?
A.A2ImpairedA2gasA2exchangeA2relatedA2toA2increasedA2bloodA2flow
B.A2FluidA2volumeA2excessA2relatedA2toA2peripheralA2vascularA2disease
C.A2RiskA2forA2injuryA2relatedA2toA2edema
D.A2AlteredA2peripheralA2tissueA2perfusionA2relatedA2toA2venousA2congestionA2-A2Ans--
D:A2(Rationale:A2ThisA2answerA2takesA2highestA2priorityA2becauseA2venousA2inflammation
A2andA2clotA2formationA2impedeA2bloodA2flowA2inA2aA2patientA2withA2deep-
veinA2thrombosis.A2OptionA2AA2isA2incorrectA2becauseA2impairedA2gasA2exchangeA2isA2rela
tedA2toA2decreased,A2notA2increased,A2bloodA2flow.A2OptionA2BA2isA2inappropriateA2becaus
eA2noA2evidenceA2suggestsA2thatA2thisA2patientA2hasA2aA2fluidA2volumeA2excess.A2OptionA2
CA2mayA2beA2warrantedA2butA2isA2secondaryA2toA2alteredA2tissueA2perfusion)
AA2nurseA2isA2revisingA2aA2client'sA2careA2plan.A2DuringA2whichA2stepA2ofA2theA2nursingA2pr
ocessA2doesA2suchA2aA2revisionA2takeA2place?
A.A2AssessmentB.A2PlanningC.A2ImplementationA2D.A2EvaluationA2-A2Ans--
D:A2(Rationale:A2DuringA2theA2evaluationA2stepA2ofA2theA2nursingA2processA2theA2nurseA2d
eterminesA2whetherA2theA2goalsA2establishedA2haveA2beenA2achieved,A2andA2evaluatesA2t
heA2successA2ofA2theA2plan.A2AnswerA2AA2involvesA2dataA2collection.A2AnswerA2BA2involve
sA2settingA2priorities,A2andA2AnswerA2CA2isA2theA2actualA2intervention
WhichA2interventionA2shouldA2theA2nurseA2inA2chargeA2tryA2firstA2forA2aA2clientA2thatA2exhibi
tsA2signsA2ofA2sleepA2disturbance?
A.A2AdministerA2sleepingA2medicationA2beforeA2bedtimeB.A2AskA2theA2clientA2eachA2morni
ngA2toA2describeA2theA2quantityA2ofA2sleepA2theA2nightA2beforeC.A2TeachA2theA2clientA2rela
xationA2techniques,A2suchA2asA2guidedA2imageryA2andA2progressiveA2muscleA2relaxation
D.A2ProvideA2theA2clientA2normalA2sleepA2aids,A2suchA2asA2pillows,A2backA2rubs,A2andA2sn
acksA2-A2Ans--D-
YouA2shouldA2beginA2withA2theA2simplestA2interventions.A2AnswerA2AA2isA2incorrectA2beca
useA2medicationsA2shouldA2beA2avoidedA2wheneverA2possible.A2AnswerA2BA2wouldA2beA2a
,A2thoroughA2sleepA2assessment,A2andA2shouldA2beA2doneA2onlyA2afterA2commonA2senseA2
interventionsA2fail.A2AnswerA2CA2wouldA2beA2appropriateA2onlyA2afterA2commonA2senseA2i
nterventionsA2fail.)
AA2nurseA2isA2assignedA2toA2careA2forA2aA2postoperativeA2maleA2clientA2whoA2hasA2diabete
sA2mellitus.A2DuringA2theA2assessmentA2interview,A2theA2clientA2reportsA2thatA2he'sA2impot
entA2andA2saysA2he'sA2concernedA2aboutA2theA2effectA2onA2hisA2marriage.A2InA2planningA2t
hisA2client'sA2care,A2theA2mostA2appropriateA2interventionA2wouldA2beA2to:A.A2EncourageA2
theA2clientA2toA2askA2questionsA2aboutA2personalA2sexualityB.A2ProvideA2timeA2forA2privac
yC.A2SuggestA2referralA2toA2aA2sexA2counselorA2orA2otherA2appropriateA2professionalD.A2P
rovideA2supportA2forA2theA2spouseA2-A2Ans--C-
MakingA2appropriateA2referralsA2isA2aA2validA2partA2ofA2planningA2theA2client'sA2care.A2TheA
2nurseA2normallyA2doesA2notA2provideA2sexA2counseling.A2WhileA2providingA2timeA2forA2pri
vacyA2andA2providingA2supportA2forA2theA2spouseA2isA2important,A2itA2isA2notA2asA2importan
tA2asA2referringA2theA2clientA2toA2aA2sexA2counselor/appropriateA2professional)
UsingA2Maslow'sA2hierarchyA2ofA2needs,A2aA2nurseA2assignsA2theA2highestA2priorityA2toA2w
hichA2clientA2need?A.A2EliminationA2B.A2SecurityA2C.A2SafetyD.A2BelongingA2-A2Ans--
A.A2AccordingA2toA2Maslow,A2eliminationA2isA2aA2first-
levelA2orA2physiologicalA2need.A2SecurityA2andA2safetyA2areA2second-
levelA2needs,A2andA2belongingA2isA2aA2third-levelA2need.)
AA2femaleA2clientA2whoA2receivedA2generalA2anesthesiaA2returnsA2fromA2surgery.A2Postop
eratively,A2whichA2nursingA2diagnosisA2takesA2highestA2priorityA2forA2thisA2client?
A.A2RiskA2forA2aspirationA2R/
TA2anesthesiaA2B.A2DeficientA2fluidA2volumeA2R/
TA2bloodA2andA2fluidA2lossA2fromA2surgeryA2C.A2ImpairedA2physicalA2mobilityA2R/
TA2surgeryA2D.A2AcuteA2painA2R/TA2surgeryA2-A2Ans--
A.A2RiskA2forA2aspirationA2takesA2priorityA2becauseA2generalA2anesthesiaA2mayA2impairA2g
agA2andA2swallowA2reflexes.A2TheA2otherA2options,A2althoughA2important,A2areA2secondar
yA2toA2this
AA2maleA2clientA2isA2admittedA2toA2theA2hospitalA2withA2bluntA2chestA2traumaA2afterA2aA2mo
torA2vehicleA2accident.A2TheA2firstA2nursingA2priorityA2forA2thisA2clientA2wouldA2beA2to:A.A2A
ssessA2theA2client'sA2airwayA2B.A2ProvideA2painA2reliefA2C.A2EncourageA2deepA2breathingA
2andA2coughingA2D.A2SplintA2theA2chestA2wallA2withA2aA2pillowA2-A2Ans--A.A2(Rationale-
A2TheA2firstA2priorityA2isA2toA2evaluateA2airwayA2patency.A2PainA2managementA2andA2splinti
ngA2areA2importantA2forA2clientA2comfort,A2butA2comeA2afterA2anA2airwayA2assessment.A2C
oughingA2andA2deepA2breathingA2mayA2beA2contraindicatedA2ifA2theA2clientA2hasA2internalA
2bleedingA2andA2otherA2injuries.)
WhenA2twoA2nursingA2diagnosesA2appearA2closelyA2related,A2whatA2shouldA2theA2nurseA2d
oA2firstA2toA2determineA2whichA2diagnosisA2mostA2accuratelyA2reflectsA2theA2needsA2ofA2aA2
patient?
A.A2ReassessA2theA2patientB.A2ExamineA2theA2relatedA2toA2factorsC.A2ReviewA2theA2defini
ngA2characteristics,D.A2AnalyzeA2theA2secondaryA2toA2factorsA2-A2Ans--C:A2Rationale-
,A2TheA2firstA2thingA2aA2nurseA2shouldA2doA2toA2differentiateA2isA2toA2compareA2theA2dataA2c
ollectedA2toA2theA2majorA2andA2minorA2definingA2characteristicsA2ofA2eachA2ofA2theA2nursin
gA2diagnosesA2beingA2considered.)
TheA2nurseA2performsA2anA2assessmentA2ofA2aA2newlyA2admittedA2patient.A2TheA2nurseA2
understandsA2thatA2thisA2admissionA2assessmentA2isA2conductedA2primarilyA2to:A.A2Diagn
oseA2ifA2theA2patientA2isA2atA2riskA2forA2falls.B.A2IdentifyA2importantA2dataC.A2EstablishA2aA2t
herapeuticA2relationshipD.A2EnsureA2thatA2theA2patient'sA2skinA2isA2intactA2-A2Ans--
B:A2(Rationale-
A2ThisA2isA2theA2primaryA2purposeA2ofA2aA2nursingA2admissionA2assessment.)
TheA2guidelinesA2forA2writingA2anA2appropriateA2nursingA2diagnosisA2includeA2allA2ofA2theA2
followingA2except:A2A.A2StateA2theA2diagnosisA2inA2termsA2ofA2aA2problem,A2notA2aA2needA2
B.A2UseA2nursingA2terminologyA2toA2describeA2theA2patient'sA2responseA2C.A2UseA2statem
entsA2thatA2assistA2inA2planningA2independentA2nursingA2interventionsA2D.A2UseA2medicalA
2terminologyA2toA2describeA2theA2probableA2causeA2ofA2theA2patient'sA2responseA2-A2Ans--
DA2(Rationale-
A2AA2nursingA2diagnosisA2isA2aA2statementA2aboutA2aA2patient'sA2actualA2orA2potentialA2hea
lthA2problemA2thatA2isA2withinA2theA2scopeA2ofA2independentA2nursingA2intervention.A2Medi
calA2terminologyA2isA2neverA2partA2ofA2theA2nursingA2diagnosis.)
IndependentA2nursingA2interventionsA2commonlyA2usedA2forA2immobilizedA2patientsA2inclu
deA2allA2ofA2theA2followingA2except:A.A2ActiveA2orA2passiveA2ROMA2exercises,A2bodyA2repo
sitioning,A2andA2ADLsA2asA2toleratedA2B.A2Deep-
breathingA2andA2coughingA2exercisesA2withA2changeA2ofA2positionA2everyA22A2hoursC.A2Di
aphragmaticA2andA2abdominalA2breathingA2exercisesD.A2WeightA2bearingA2onA2aA2tiltA2tab
le,A2totalA2parenteralA2nutrition,A2andA2vitaminA2therapyA2-A2Ans--
(Answer:A2)A2D(Rationale-
A2A,A2B,A2&A2CA2areA2incorrect.A2TheseA2areA2notA2independentA2nursingA2interventionsA2b
ecauseA2theyA2requireA2aA2physician'sA2order.)
IndependentA2nursingA2interventionsA2commonlyA2usedA2forA2patientsA2withA2pressureA2ul
cersA2include:A.A2changingA2theA2patient'sA2positionA2regularlyA2toA2minimizeA2pressureB.
A2ApplyingA2aA2dryingA2agentA2suchA2asA2anA2antacidA2toA2decreaseA2moistureA2atA2theA2ul
cerA2siteC.A2DebridingA2theA2ulcerA2toA2removeA2necroticA2tissue,A2whichA2canA2impedeA2h
ealingD.A2PlacingA2theA2patientA2inA2aA2whirlpoolA2bathA2containingA2povidone-
iodineA2solutionA2asA2toleratedA2-A2Ans--(Answer:A2)A2A(Rationale-
A2IndependentA2nursingA2interventionsA2forA2aA2patientA2withA2pressureA2ulcersA2commonl
yA2includeA2changingA2positions.A2B,A2C,A2&A2DA2allA2requireA2aA2physician'sA2order.A2Addit
ionally,A2aA2dryingA2agent,A2answerA2BA2wouldA2beA2contraindicatedA2becauseA2theA2woun
dA2needsA2moistureA2toA2heal.)
WhileA2theA2nurseA2isA2providingA2aA2patientA2personalA2hygiene,A2sheA2observesA2thatA2h
isA2skinA2isA2excessivelyA2dry.A2DuringA2theA2procedure,A2heA2tellsA2herA2thatA2heA2isA2very
A2thirsty.A2AnA2appropriate A2nursingA2diagnosisA2wouldA2be:A.A2PotentialA2forA2impairedA2s
kinA2integrityA2R/
, TA2alteredA2glandA2functionB.A2PotentialA2forA2impairedA2skinA2integrityA2R/
TA2dehydrationC.A2ImpairedA2skinA2integrityA2R/
TA2dehydrationA2D.A2ImpairedA2skinA2integrityA2R/TA2alteredA2circulationA2-A2Ans--
(Answer:A2)A2C(Rationale-
A2TheA2appropriate A2diagnosisA2forA2aA2patientA2withA2excessivelyA2dryA2skinA2isA2impaired
A2skinA2integrityA2-
A2actualA2notA2potential.A2R/
TA2dehydrationA2isA2appropriateA2becauseA2theA2patientA2complainedA2ofA2thirst.)
TheA2mostA2importantA2nursingA2interventionA2toA2correctA2skinA2drynessA2is:A.A2avoidA2ba
thingA2untilA2theA2conditionA2isA2remediedA2andA2notifyA2physicianB.A2askA2physicianA2toA2r
eferA2theA2patientA2toA2aA2dermatologistA2C.A2ConsultA2theA2dietitianA2aboutA2increasingA2f
atA2intake,A2andA2takeA2necessaryA2measuresA2toA2preventA2infectionD.A2encourageA2theA
2patientA2toA2increaseA2fluidA2intake,A2useA2nonirritatingA2soap,A2andA2applyA2lotionA2toA2in
volvedA2areasA2-A2Ans--(Answer:A2)A2D(Rationale-
A2PreventativeA2measures,A2suchA2asA2these,A2willA2preventA2theA2skinA2fromA2cracking,A2
whichA2wouldA2makeA2theA2clientA2moreA2proneA2toA2infection.A2TheA2otherA23A2answersA2
areA2options,A2howeverA2NOTA2theA2bestA2choiceA2forA2thisA2particularA2situation.)
WhichA2ofA2theA2followingA2isA2anA2appropriatelyA2writtenA2nursingA2diagnosis?
A2A)A2PainA2relatedA2toA2insufficientA2useA2ofA2medicationA2B)A2PainA2relatedA2toA2difficulty
A2ambulatingC)A2AnxietyA2relatedA2toA2cardiacA2monitorD)A2BedpanA2requiredA2frequently
A2asA2aA2resultA2ofA2alteredA2eliminationA2patternA2-A2Ans--(Answer:A2)A2AA2(Rationale-
A2A.A2ThisA2isA2anA2exampleA2ofA2anA2appropriatelyA2writtenA2nursingA2diagnosis.A2ItA2cons
istsA2ofA2aA2diagnosticA2labelA2andA2theA2associatedA2etiology.A2NursingA2interventionsA2c
anA2beA2directedA2atA2treatingA2orA2managingA2theA2behaviorA2ofA2insufficientA2medication
A2use.A2note:A2forA2purposesA2ofA2thisA2exampleA2thereA2areA2noA2signsA2andA2symptomsA2
listed.A2InA2anA2actualA2diagnosisA2theA2S/
SA2wouldA2needA2toA2beA2listedA2asA2well.B.A2ThisA2nursingA2diagnosisA2isA2notA2writtenA2c
orrectly.A2WhatA2couldA2beA2aA2definingA2characteristicA2S/
SA2isA2usedA2asA2anA2etiology.A2ThisA2nursingA2diagnosisA2couldA2beA2rewrittenA2moreA2ap
propriatelyA2asA2ImpairedA2mobilityA2relatedA2toA2painA2asA2evidencedA2byA2difficultyA2amb
ulating.A2C.A2ThisA2nursingA2diagnosisA2isA2writtenA2incorrectlyA2becauseA2itA2identifiesA2th
eA2equipmentA2ratherA2thanA2theA2client'sA2responseA2toA2theA2equipment.A2ItA2wouldA2beA
2appropriate A2toA2stateA2deficientA2knowledgeA2regardingA2theA2needA2forA2cardiacA2monit
oring.A2D.A2ThisA2nursingA2diagnosisA2isA2writtenA2incorrectlyA2becauseA2itA2identifiesA2aA2
nursingA2intervention,A2notA2theA2client'sA2problem.A2ItA2couldA2beA2reworded,A2DiarrheaA2r
elatedA2toA2foodA2intoleranceA2forA2example.)
DiagnosisA2mustA2haveA2aA2-A2Ans--
1.A2DiagnosticA2labelA2andA22.A2AssociatedA2etiology,A23.A2signsA2ansA2symptomsA2asA2we
llA2
NURSINGA2DIAGNOSISA2FOCUSESA2ONA2CLIENTA2NEEDS
AccountabilityA2isA2aA2criticalA2aspectA2ofA2nursingA2care.A2AnA2exampleA2ofA2accountabilit
yA2isA2demonstratedA2by:A2A)A2SelectingA2theA2medicationA2scheduleA2forA2theA2clientB)A2I
102 QUESTIONS AND CORRECT
ANSWERS
TheA2nurseA2inA2chargeA2identifiesA2aA2patient'sA2responsesA2toA2actualA2orA2potentialA2he
althA2problemsA2duringA2whichA2stepA2ofA2theA2nursingA2process?A2-A2Ans--
Diagnosis:A2TheA2nurseA2identifiesA2humanA2responsesA2toA2actualA2orA2potentialA2healthA
2problemsA2duringA2theA2nursingA2diagnosesA2stepA2ofA2theA2nursingA2process.A2DuringA2t
heA2assessmentA2step,A2theA2nurseA2collectsA2data.A2DuringA2theA2planningA2step,A2theA2n
urseA2developsA2strategiesA2toA2resolveA2orA2decreaseA2theA2patient'sA2problem.A2DuringA
2evaluation,A2theA2nurseA2determinesA2theA2effectivenessA2ofA2theA2planA2ofA2care
AA2femaleA2patientA2isA2diagnosedA2withA2deep-
veinA2thrombosis.A2WhichA2nursingA2diagnosisA2shouldA2receiveA2theA2highestA2priorityA2a
tA2thisA2time?
A.A2ImpairedA2gasA2exchangeA2relatedA2toA2increasedA2bloodA2flow
B.A2FluidA2volumeA2excessA2relatedA2toA2peripheralA2vascularA2disease
C.A2RiskA2forA2injuryA2relatedA2toA2edema
D.A2AlteredA2peripheralA2tissueA2perfusionA2relatedA2toA2venousA2congestionA2-A2Ans--
D:A2(Rationale:A2ThisA2answerA2takesA2highestA2priorityA2becauseA2venousA2inflammation
A2andA2clotA2formationA2impedeA2bloodA2flowA2inA2aA2patientA2withA2deep-
veinA2thrombosis.A2OptionA2AA2isA2incorrectA2becauseA2impairedA2gasA2exchangeA2isA2rela
tedA2toA2decreased,A2notA2increased,A2bloodA2flow.A2OptionA2BA2isA2inappropriateA2becaus
eA2noA2evidenceA2suggestsA2thatA2thisA2patientA2hasA2aA2fluidA2volumeA2excess.A2OptionA2
CA2mayA2beA2warrantedA2butA2isA2secondaryA2toA2alteredA2tissueA2perfusion)
AA2nurseA2isA2revisingA2aA2client'sA2careA2plan.A2DuringA2whichA2stepA2ofA2theA2nursingA2pr
ocessA2doesA2suchA2aA2revisionA2takeA2place?
A.A2AssessmentB.A2PlanningC.A2ImplementationA2D.A2EvaluationA2-A2Ans--
D:A2(Rationale:A2DuringA2theA2evaluationA2stepA2ofA2theA2nursingA2processA2theA2nurseA2d
eterminesA2whetherA2theA2goalsA2establishedA2haveA2beenA2achieved,A2andA2evaluatesA2t
heA2successA2ofA2theA2plan.A2AnswerA2AA2involvesA2dataA2collection.A2AnswerA2BA2involve
sA2settingA2priorities,A2andA2AnswerA2CA2isA2theA2actualA2intervention
WhichA2interventionA2shouldA2theA2nurseA2inA2chargeA2tryA2firstA2forA2aA2clientA2thatA2exhibi
tsA2signsA2ofA2sleepA2disturbance?
A.A2AdministerA2sleepingA2medicationA2beforeA2bedtimeB.A2AskA2theA2clientA2eachA2morni
ngA2toA2describeA2theA2quantityA2ofA2sleepA2theA2nightA2beforeC.A2TeachA2theA2clientA2rela
xationA2techniques,A2suchA2asA2guidedA2imageryA2andA2progressiveA2muscleA2relaxation
D.A2ProvideA2theA2clientA2normalA2sleepA2aids,A2suchA2asA2pillows,A2backA2rubs,A2andA2sn
acksA2-A2Ans--D-
YouA2shouldA2beginA2withA2theA2simplestA2interventions.A2AnswerA2AA2isA2incorrectA2beca
useA2medicationsA2shouldA2beA2avoidedA2wheneverA2possible.A2AnswerA2BA2wouldA2beA2a
,A2thoroughA2sleepA2assessment,A2andA2shouldA2beA2doneA2onlyA2afterA2commonA2senseA2
interventionsA2fail.A2AnswerA2CA2wouldA2beA2appropriateA2onlyA2afterA2commonA2senseA2i
nterventionsA2fail.)
AA2nurseA2isA2assignedA2toA2careA2forA2aA2postoperativeA2maleA2clientA2whoA2hasA2diabete
sA2mellitus.A2DuringA2theA2assessmentA2interview,A2theA2clientA2reportsA2thatA2he'sA2impot
entA2andA2saysA2he'sA2concernedA2aboutA2theA2effectA2onA2hisA2marriage.A2InA2planningA2t
hisA2client'sA2care,A2theA2mostA2appropriateA2interventionA2wouldA2beA2to:A.A2EncourageA2
theA2clientA2toA2askA2questionsA2aboutA2personalA2sexualityB.A2ProvideA2timeA2forA2privac
yC.A2SuggestA2referralA2toA2aA2sexA2counselorA2orA2otherA2appropriateA2professionalD.A2P
rovideA2supportA2forA2theA2spouseA2-A2Ans--C-
MakingA2appropriateA2referralsA2isA2aA2validA2partA2ofA2planningA2theA2client'sA2care.A2TheA
2nurseA2normallyA2doesA2notA2provideA2sexA2counseling.A2WhileA2providingA2timeA2forA2pri
vacyA2andA2providingA2supportA2forA2theA2spouseA2isA2important,A2itA2isA2notA2asA2importan
tA2asA2referringA2theA2clientA2toA2aA2sexA2counselor/appropriateA2professional)
UsingA2Maslow'sA2hierarchyA2ofA2needs,A2aA2nurseA2assignsA2theA2highestA2priorityA2toA2w
hichA2clientA2need?A.A2EliminationA2B.A2SecurityA2C.A2SafetyD.A2BelongingA2-A2Ans--
A.A2AccordingA2toA2Maslow,A2eliminationA2isA2aA2first-
levelA2orA2physiologicalA2need.A2SecurityA2andA2safetyA2areA2second-
levelA2needs,A2andA2belongingA2isA2aA2third-levelA2need.)
AA2femaleA2clientA2whoA2receivedA2generalA2anesthesiaA2returnsA2fromA2surgery.A2Postop
eratively,A2whichA2nursingA2diagnosisA2takesA2highestA2priorityA2forA2thisA2client?
A.A2RiskA2forA2aspirationA2R/
TA2anesthesiaA2B.A2DeficientA2fluidA2volumeA2R/
TA2bloodA2andA2fluidA2lossA2fromA2surgeryA2C.A2ImpairedA2physicalA2mobilityA2R/
TA2surgeryA2D.A2AcuteA2painA2R/TA2surgeryA2-A2Ans--
A.A2RiskA2forA2aspirationA2takesA2priorityA2becauseA2generalA2anesthesiaA2mayA2impairA2g
agA2andA2swallowA2reflexes.A2TheA2otherA2options,A2althoughA2important,A2areA2secondar
yA2toA2this
AA2maleA2clientA2isA2admittedA2toA2theA2hospitalA2withA2bluntA2chestA2traumaA2afterA2aA2mo
torA2vehicleA2accident.A2TheA2firstA2nursingA2priorityA2forA2thisA2clientA2wouldA2beA2to:A.A2A
ssessA2theA2client'sA2airwayA2B.A2ProvideA2painA2reliefA2C.A2EncourageA2deepA2breathingA
2andA2coughingA2D.A2SplintA2theA2chestA2wallA2withA2aA2pillowA2-A2Ans--A.A2(Rationale-
A2TheA2firstA2priorityA2isA2toA2evaluateA2airwayA2patency.A2PainA2managementA2andA2splinti
ngA2areA2importantA2forA2clientA2comfort,A2butA2comeA2afterA2anA2airwayA2assessment.A2C
oughingA2andA2deepA2breathingA2mayA2beA2contraindicatedA2ifA2theA2clientA2hasA2internalA
2bleedingA2andA2otherA2injuries.)
WhenA2twoA2nursingA2diagnosesA2appearA2closelyA2related,A2whatA2shouldA2theA2nurseA2d
oA2firstA2toA2determineA2whichA2diagnosisA2mostA2accuratelyA2reflectsA2theA2needsA2ofA2aA2
patient?
A.A2ReassessA2theA2patientB.A2ExamineA2theA2relatedA2toA2factorsC.A2ReviewA2theA2defini
ngA2characteristics,D.A2AnalyzeA2theA2secondaryA2toA2factorsA2-A2Ans--C:A2Rationale-
,A2TheA2firstA2thingA2aA2nurseA2shouldA2doA2toA2differentiateA2isA2toA2compareA2theA2dataA2c
ollectedA2toA2theA2majorA2andA2minorA2definingA2characteristicsA2ofA2eachA2ofA2theA2nursin
gA2diagnosesA2beingA2considered.)
TheA2nurseA2performsA2anA2assessmentA2ofA2aA2newlyA2admittedA2patient.A2TheA2nurseA2
understandsA2thatA2thisA2admissionA2assessmentA2isA2conductedA2primarilyA2to:A.A2Diagn
oseA2ifA2theA2patientA2isA2atA2riskA2forA2falls.B.A2IdentifyA2importantA2dataC.A2EstablishA2aA2t
herapeuticA2relationshipD.A2EnsureA2thatA2theA2patient'sA2skinA2isA2intactA2-A2Ans--
B:A2(Rationale-
A2ThisA2isA2theA2primaryA2purposeA2ofA2aA2nursingA2admissionA2assessment.)
TheA2guidelinesA2forA2writingA2anA2appropriateA2nursingA2diagnosisA2includeA2allA2ofA2theA2
followingA2except:A2A.A2StateA2theA2diagnosisA2inA2termsA2ofA2aA2problem,A2notA2aA2needA2
B.A2UseA2nursingA2terminologyA2toA2describeA2theA2patient'sA2responseA2C.A2UseA2statem
entsA2thatA2assistA2inA2planningA2independentA2nursingA2interventionsA2D.A2UseA2medicalA
2terminologyA2toA2describeA2theA2probableA2causeA2ofA2theA2patient'sA2responseA2-A2Ans--
DA2(Rationale-
A2AA2nursingA2diagnosisA2isA2aA2statementA2aboutA2aA2patient'sA2actualA2orA2potentialA2hea
lthA2problemA2thatA2isA2withinA2theA2scopeA2ofA2independentA2nursingA2intervention.A2Medi
calA2terminologyA2isA2neverA2partA2ofA2theA2nursingA2diagnosis.)
IndependentA2nursingA2interventionsA2commonlyA2usedA2forA2immobilizedA2patientsA2inclu
deA2allA2ofA2theA2followingA2except:A.A2ActiveA2orA2passiveA2ROMA2exercises,A2bodyA2repo
sitioning,A2andA2ADLsA2asA2toleratedA2B.A2Deep-
breathingA2andA2coughingA2exercisesA2withA2changeA2ofA2positionA2everyA22A2hoursC.A2Di
aphragmaticA2andA2abdominalA2breathingA2exercisesD.A2WeightA2bearingA2onA2aA2tiltA2tab
le,A2totalA2parenteralA2nutrition,A2andA2vitaminA2therapyA2-A2Ans--
(Answer:A2)A2D(Rationale-
A2A,A2B,A2&A2CA2areA2incorrect.A2TheseA2areA2notA2independentA2nursingA2interventionsA2b
ecauseA2theyA2requireA2aA2physician'sA2order.)
IndependentA2nursingA2interventionsA2commonlyA2usedA2forA2patientsA2withA2pressureA2ul
cersA2include:A.A2changingA2theA2patient'sA2positionA2regularlyA2toA2minimizeA2pressureB.
A2ApplyingA2aA2dryingA2agentA2suchA2asA2anA2antacidA2toA2decreaseA2moistureA2atA2theA2ul
cerA2siteC.A2DebridingA2theA2ulcerA2toA2removeA2necroticA2tissue,A2whichA2canA2impedeA2h
ealingD.A2PlacingA2theA2patientA2inA2aA2whirlpoolA2bathA2containingA2povidone-
iodineA2solutionA2asA2toleratedA2-A2Ans--(Answer:A2)A2A(Rationale-
A2IndependentA2nursingA2interventionsA2forA2aA2patientA2withA2pressureA2ulcersA2commonl
yA2includeA2changingA2positions.A2B,A2C,A2&A2DA2allA2requireA2aA2physician'sA2order.A2Addit
ionally,A2aA2dryingA2agent,A2answerA2BA2wouldA2beA2contraindicatedA2becauseA2theA2woun
dA2needsA2moistureA2toA2heal.)
WhileA2theA2nurseA2isA2providingA2aA2patientA2personalA2hygiene,A2sheA2observesA2thatA2h
isA2skinA2isA2excessivelyA2dry.A2DuringA2theA2procedure,A2heA2tellsA2herA2thatA2heA2isA2very
A2thirsty.A2AnA2appropriate A2nursingA2diagnosisA2wouldA2be:A.A2PotentialA2forA2impairedA2s
kinA2integrityA2R/
, TA2alteredA2glandA2functionB.A2PotentialA2forA2impairedA2skinA2integrityA2R/
TA2dehydrationC.A2ImpairedA2skinA2integrityA2R/
TA2dehydrationA2D.A2ImpairedA2skinA2integrityA2R/TA2alteredA2circulationA2-A2Ans--
(Answer:A2)A2C(Rationale-
A2TheA2appropriate A2diagnosisA2forA2aA2patientA2withA2excessivelyA2dryA2skinA2isA2impaired
A2skinA2integrityA2-
A2actualA2notA2potential.A2R/
TA2dehydrationA2isA2appropriateA2becauseA2theA2patientA2complainedA2ofA2thirst.)
TheA2mostA2importantA2nursingA2interventionA2toA2correctA2skinA2drynessA2is:A.A2avoidA2ba
thingA2untilA2theA2conditionA2isA2remediedA2andA2notifyA2physicianB.A2askA2physicianA2toA2r
eferA2theA2patientA2toA2aA2dermatologistA2C.A2ConsultA2theA2dietitianA2aboutA2increasingA2f
atA2intake,A2andA2takeA2necessaryA2measuresA2toA2preventA2infectionD.A2encourageA2theA
2patientA2toA2increaseA2fluidA2intake,A2useA2nonirritatingA2soap,A2andA2applyA2lotionA2toA2in
volvedA2areasA2-A2Ans--(Answer:A2)A2D(Rationale-
A2PreventativeA2measures,A2suchA2asA2these,A2willA2preventA2theA2skinA2fromA2cracking,A2
whichA2wouldA2makeA2theA2clientA2moreA2proneA2toA2infection.A2TheA2otherA23A2answersA2
areA2options,A2howeverA2NOTA2theA2bestA2choiceA2forA2thisA2particularA2situation.)
WhichA2ofA2theA2followingA2isA2anA2appropriatelyA2writtenA2nursingA2diagnosis?
A2A)A2PainA2relatedA2toA2insufficientA2useA2ofA2medicationA2B)A2PainA2relatedA2toA2difficulty
A2ambulatingC)A2AnxietyA2relatedA2toA2cardiacA2monitorD)A2BedpanA2requiredA2frequently
A2asA2aA2resultA2ofA2alteredA2eliminationA2patternA2-A2Ans--(Answer:A2)A2AA2(Rationale-
A2A.A2ThisA2isA2anA2exampleA2ofA2anA2appropriatelyA2writtenA2nursingA2diagnosis.A2ItA2cons
istsA2ofA2aA2diagnosticA2labelA2andA2theA2associatedA2etiology.A2NursingA2interventionsA2c
anA2beA2directedA2atA2treatingA2orA2managingA2theA2behaviorA2ofA2insufficientA2medication
A2use.A2note:A2forA2purposesA2ofA2thisA2exampleA2thereA2areA2noA2signsA2andA2symptomsA2
listed.A2InA2anA2actualA2diagnosisA2theA2S/
SA2wouldA2needA2toA2beA2listedA2asA2well.B.A2ThisA2nursingA2diagnosisA2isA2notA2writtenA2c
orrectly.A2WhatA2couldA2beA2aA2definingA2characteristicA2S/
SA2isA2usedA2asA2anA2etiology.A2ThisA2nursingA2diagnosisA2couldA2beA2rewrittenA2moreA2ap
propriatelyA2asA2ImpairedA2mobilityA2relatedA2toA2painA2asA2evidencedA2byA2difficultyA2amb
ulating.A2C.A2ThisA2nursingA2diagnosisA2isA2writtenA2incorrectlyA2becauseA2itA2identifiesA2th
eA2equipmentA2ratherA2thanA2theA2client'sA2responseA2toA2theA2equipment.A2ItA2wouldA2beA
2appropriate A2toA2stateA2deficientA2knowledgeA2regardingA2theA2needA2forA2cardiacA2monit
oring.A2D.A2ThisA2nursingA2diagnosisA2isA2writtenA2incorrectlyA2becauseA2itA2identifiesA2aA2
nursingA2intervention,A2notA2theA2client'sA2problem.A2ItA2couldA2beA2reworded,A2DiarrheaA2r
elatedA2toA2foodA2intoleranceA2forA2example.)
DiagnosisA2mustA2haveA2aA2-A2Ans--
1.A2DiagnosticA2labelA2andA22.A2AssociatedA2etiology,A23.A2signsA2ansA2symptomsA2asA2we
llA2
NURSINGA2DIAGNOSISA2FOCUSESA2ONA2CLIENTA2NEEDS
AccountabilityA2isA2aA2criticalA2aspectA2ofA2nursingA2care.A2AnA2exampleA2ofA2accountabilit
yA2isA2demonstratedA2by:A2A)A2SelectingA2theA2medicationA2scheduleA2forA2theA2clientB)A2I
