Nursing Process/Diagnoses Practice
Test (NCLEX style) 15 multiple choice
GRADED A.
The nurse in charge identifies a patient's responses to actual or potential health
problems during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating - answerAnswer: B
Rationale- The nurse identifies human responses to actual or potential health problems
during the nursing diagnoses step of the nursing process. During the assessment step,
the nurse collects data. During the planning step, the nurse develops strategies to
resolve or decrease the patient's problem. During evaluation, the nurse determines the
effectiveness of the plan of care.
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis
should receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion - answerAnswer: D
Rationale: This answer takes highest priority because venous inflammation and clot
formation impede blood flow in a patient with deep-vein thrombosis.
Option A is incorrect because impaired gas exchange is related to decreased, not
increased, blood flow. Option B is inappropriate because no evidence suggests that this
patient has a fluid volume excess. Option C may be warranted but is secondary to
altered tissue perfusion
A nurse is revising a client's care plan. During which step of the nursing process does
such a revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation - answerAnswer: D
Rationale: During the evaluation step of the nursing process the nurse determines
whether the goals established have been achieved, and evaluates the success of the
plan. Answer A involves data collection. Answer B involves setting priorities, and
Answer C is the actual intervention.
, Nursing Process/Diagnoses Practice
Test (NCLEX style) 15 multiple choice
GRADED A.
Which intervention should the nurse in charge try first for a client that exhibits signs of
sleep disturbance?
A. Administer sleeping medication before bedtime
B. Ask the client each morning to describe the quantity of sleep the night before
C. Teach the client relaxation techniques, such as guided imagery and progressive
muscle relaxation
D. Provide the client normal sleep aids, such as pillows, back rubs, and snacks -
answerAnswer: D
Rationale: You should begin with the simplest interventions. Answer A is incorrect
because medications should be avoided whenever possible. Answer B would be a
thorough sleep assessment, and should be done only after common sense interventions
fail. Answer C would be appropriate only after common sense interventions fail.
A nurse is assigned to care for a postoperative male client who has diabetes mellitus.
During the assessment interview, the client reports that he's impotent and says he's
concerned about the effect on his marriage. In planning this client's care, the most
appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex counselor or other appropriate professional
D. Provide support for the spouse - answerAnswer: C
Rationale- Making appropriate referrals is a valid part of planning the client's care. The
nurse normally does not provide sex counseling. While providing time for privacy and
providing support for the spouse is important, it is not as important as referring the client
to a sex counselor/appropriate professional.
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client
need?
A. Elimination
B. Security
C. Safety
D. Belonging - answerAnswer- A
Rationale - According to Maslow, elimination is a first-level or physiological need.
Security and safety are second-level needs, and belonging is a third-level need.
Test (NCLEX style) 15 multiple choice
GRADED A.
The nurse in charge identifies a patient's responses to actual or potential health
problems during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating - answerAnswer: B
Rationale- The nurse identifies human responses to actual or potential health problems
during the nursing diagnoses step of the nursing process. During the assessment step,
the nurse collects data. During the planning step, the nurse develops strategies to
resolve or decrease the patient's problem. During evaluation, the nurse determines the
effectiveness of the plan of care.
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis
should receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion - answerAnswer: D
Rationale: This answer takes highest priority because venous inflammation and clot
formation impede blood flow in a patient with deep-vein thrombosis.
Option A is incorrect because impaired gas exchange is related to decreased, not
increased, blood flow. Option B is inappropriate because no evidence suggests that this
patient has a fluid volume excess. Option C may be warranted but is secondary to
altered tissue perfusion
A nurse is revising a client's care plan. During which step of the nursing process does
such a revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation - answerAnswer: D
Rationale: During the evaluation step of the nursing process the nurse determines
whether the goals established have been achieved, and evaluates the success of the
plan. Answer A involves data collection. Answer B involves setting priorities, and
Answer C is the actual intervention.
, Nursing Process/Diagnoses Practice
Test (NCLEX style) 15 multiple choice
GRADED A.
Which intervention should the nurse in charge try first for a client that exhibits signs of
sleep disturbance?
A. Administer sleeping medication before bedtime
B. Ask the client each morning to describe the quantity of sleep the night before
C. Teach the client relaxation techniques, such as guided imagery and progressive
muscle relaxation
D. Provide the client normal sleep aids, such as pillows, back rubs, and snacks -
answerAnswer: D
Rationale: You should begin with the simplest interventions. Answer A is incorrect
because medications should be avoided whenever possible. Answer B would be a
thorough sleep assessment, and should be done only after common sense interventions
fail. Answer C would be appropriate only after common sense interventions fail.
A nurse is assigned to care for a postoperative male client who has diabetes mellitus.
During the assessment interview, the client reports that he's impotent and says he's
concerned about the effect on his marriage. In planning this client's care, the most
appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex counselor or other appropriate professional
D. Provide support for the spouse - answerAnswer: C
Rationale- Making appropriate referrals is a valid part of planning the client's care. The
nurse normally does not provide sex counseling. While providing time for privacy and
providing support for the spouse is important, it is not as important as referring the client
to a sex counselor/appropriate professional.
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client
need?
A. Elimination
B. Security
C. Safety
D. Belonging - answerAnswer- A
Rationale - According to Maslow, elimination is a first-level or physiological need.
Security and safety are second-level needs, and belonging is a third-level need.
