Exam (elaborations) NURS 101 Nclex-Exam Practice p164

Introduction A 24-item NCLEX style exam all about the ADPIE or the Nursing Process. Topics  Nursing Process Guidelines  Read each question carefully and choose the best answer.  You are given one minute per question. Spend your time wisely!  Answers and rationales are given below. Be sure to read them.  If you need more clarifications, please direct them to the comments section. Questions 1. Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a: 1. Plan is developed for nursing care. 2. Physical assessment begins 3. List of priorities is determined. 4. Review of the assessment is conducted with other team members. 2. Planning is a category of nursing behaviors in which: 1. The nurse determines the health care needed for the client. 2. The Physician determines the plan of care for the client. 3. Client-centered goals and expected outcomes are established. 4. The client determines the care needed. 3. Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client’s: 1. Physician 2. Non Emergent, non-life threatening needs 3. Future well-being. 4. Urgency of problems 4. A client centered goal is a specific and measurable behavior or response that reflects a client’s: 1. Desire for specific health care interventions 2. Highest possible level of wellness and independence in function. 3. Physician’s goal for the specific client. 4. Response when compared to another client with a like problem. 5. For clients to participate in goal setting, they should be: 1. Alert and have some degree of independence. 2. Ambulatory and mobile. 3. Able to speak and write. 4. Able to read and write. 6. The nurse writes an expected outcome statement in measurable terms. An example is: 1. Client will have less pain. 2. Client will be pain free. 3. Client will report pain acuity less than 4 on a scale of 0-10. 4. Client will take pain medication every 4 hours around the clock.