ACTUAL EXAM TEST BANK| COMPLETE QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED
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1. Which resource is most helpful when prioritizing identified
nursing diagnoses?
A) Nursing Interventions Classification (NIC)
B) Gordon's Functional Health Patterns
C) Maslow's Hierarchy of Needs
D) Nursing Outcomes Classification (NOC)
Answer: C
Rationale: Maslow's Hierarchy of Needs provides a framework for
prioritizing nursing diagnoses by identifying which needs must be
addressed first. Physiological needs (airway, breathing, circulation)
take priority over safety, love/belonging, esteem, and self-
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,actualization needs. This is a fundamental concept in nursing
prioritization .
2. What is the most important reason for nurses to use
standardized taxonomy such as the ICNP, CCC, or NANDA?
A) Insurance documentation
B) Professional autonomy
C) EMR data analysis
D) Patient safety
Answer: D
Rationale: Standardized nursing language improves communication
among healthcare providers, reduces errors, and enhances patient
safety. While documentation and data analysis are benefits, patient
safety is the primary reason for using standardized terminology .
3. Which nursing diagnosis statements are appropriately written
according to the NANDA format? (Select all that apply)
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,A) Risk for infection related to elevated temperature and WBC
B) Readiness for effective family process as evidenced by
expressed desire for improved communication
C) Impaired health maintenance related to inability to access
care as evidenced by failure to keep appointments
D) Risk for hemorrhaging as evidenced by prolonged clotting
time
E) Chronic pain related to osteoarthritis as manifested by
verbalized postoperative discomfort
Answer: B, C, D
Rationale: Proper NANDA format includes the diagnosis, related
factors (etiology), and defining characteristics (evidence). Risk
diagnoses use "risk for" without evidenced by. A is incorrect
because risk diagnoses do not use "related to" with
signs/symptoms. E incorrectly uses "manifested by" for a chronic
diagnosis. Correct formulations follow the PES (Problem, Etiology,
Signs/Symptoms) format .
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, 4. Which direct-care intervention would be most effective in
helping a patient cope emotionally with a new diagnosis of
cancer?
A) Reassessing for changes in the patient's physical condition
B) Teaching the patient various methods of stress reduction
C) Referring the patient for music and massage therapy
D) Encouraging the patient to explore options for care
Answer: D
Rationale: Encouraging the patient to explore care options
empowers them and addresses emotional coping needs. This direct-
care intervention focuses on the patient's emotional response to
diagnosis. While stress reduction and complementary therapies may
help, exploring options directly addresses coping and autonomy .
5. What should be taken into consideration by the nurse when
deciding on interventions to include in a patient's plan of care?
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