Fundamentals of Nursing, Nursing Process
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital
signs, the nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation -ans A. Assessment
Rationale: The first step in the nursing process is assessment, the process of collecting data. All subsequent
phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data.
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." -ans 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.
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 -ans 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.
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 -ans 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.
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 -ans 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.
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 -ans 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.
During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for
today?"
A. Introduction
B. Body
C. Closing
D. Orientation -ans A. Introduction
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital
signs, the nurse is implementing which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation -ans A. Assessment
Rationale: The first step in the nursing process is assessment, the process of collecting data. All subsequent
phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data.
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." -ans 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.
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 -ans 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.
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 -ans 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.
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 -ans 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.
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 -ans 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.
During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for
today?"
A. Introduction
B. Body
C. Closing
D. Orientation -ans A. Introduction
