Fundamentals to nursing ch 11 2025
The student is learning the steps of the nursing process. What is the first thing that the
student should realize about the purpose of this process?
1. Deliver care to a client in an organized way.
2. Implement a plan that is close to the medical model.
3. Identify client needs and deliver care to meet those needs.
4. Make sure that standardized care is available to clients. - ANSWERSCorrect Answer:
3
While conducting a dressing change, the nurse notes a new area of skin breakdown
that was caused from the tape used to secure the dressing. In which phase of the
nursing process is the nurse working?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation - ANSWERSCorrect Answer: 1
During an assessment, a client who is not very talkative appears pale, diaphoretic, and
restless in the bed, and says "leave me alone." Which subjective data should the nurse
document?
1. Restlessness
2. "Leave me alone"
3. Not talkative
4. Pale and diaphoretic - ANSWERSCorrect Answer: 2
Family of a client demonstrating confusion state that this is not the client's usual
behavior. How should the nurse document this data?
1. Inference
2. Subjective data
3. Objective data
4. Secondary subjective data - ANSWERSCorrect Answer: 3
The nurse provides a back rub to a client after administering a pain medication with the
hope that these two actions will help decrease the client's pain. Which phase of the
nursing process is this nurse implementing?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation - ANSWERSCorrect Answer: 3
A new client has been admitted to the care area. How soon should the nurse plan to
complete a physical assessment on this patient?
1. 1 hour
2. 12 hours
, 3. 48 hours
4. 24 hours - ANSWERSCorrect Answer: 4
The nurse is admitting an infant to the care area. The parents and grandmother are
present. What should the nurse use as the best source of data for this client?
1. Medical record from the child's birth
2. Grandmother
3. Parents
4. Admitting physician - ANSWERSCorrect Answer: 3
A newly admitted client is angry because nursing staff continue to ask the same
questions. What should the nurse respond to this client?
1. "In order to make sure all of your information is complete, I need to ask these
questions."
2. "You're right. Let me know if there's anything you need right now."
3. "I'll be done shortly, just give me a few more minutes."
4. "You shouldn't be upset. We're only doing our jobs." - ANSWERSCorrect Answer: 2
The nurse documents: "Client avoids eye contact and gives only vague, nonspecific
answers to direct questioning by the professional staff. Is quite animated (laughs aloud,
smiles, uses hand gestures) in conversation with spouse." Which method of data
collection does this documentation demonstrate?
1. Examining
2. Interviewing
3. Listening
4. Observing - ANSWERSCorrect Answer: 4
A nurse has worked in the trauma critical care area for several years. Which noise may
become indiscriminate for this particular nurse?
1. A client with audible breathing
2. Moaning of a client in pain
3. Whirring of ventilators
4. Co-orkers discussing their clients' conditions - ANSWERSCorrect Answer: 3
A client has been using the call light routinely throughout the evening. Upon entering
the room, the nurse observes the following details. Organize them according to priority
sequencing (1 is first priority; 5 is least priority).
Standard Text: Click and drag the options below to move them up or down.
Choice 1. The family is at the bedside.
Choice 2. The IV pump is running on battery.
Choice 3. The ECG monitor shows tachycardia.
Choice 4. The client reports being restless.
Choice 5. O2 tubing is not attached to wall regulator. - ANSWERSCorrect Answer: 3, 4,
5, 2, 1
The student is learning the steps of the nursing process. What is the first thing that the
student should realize about the purpose of this process?
1. Deliver care to a client in an organized way.
2. Implement a plan that is close to the medical model.
3. Identify client needs and deliver care to meet those needs.
4. Make sure that standardized care is available to clients. - ANSWERSCorrect Answer:
3
While conducting a dressing change, the nurse notes a new area of skin breakdown
that was caused from the tape used to secure the dressing. In which phase of the
nursing process is the nurse working?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation - ANSWERSCorrect Answer: 1
During an assessment, a client who is not very talkative appears pale, diaphoretic, and
restless in the bed, and says "leave me alone." Which subjective data should the nurse
document?
1. Restlessness
2. "Leave me alone"
3. Not talkative
4. Pale and diaphoretic - ANSWERSCorrect Answer: 2
Family of a client demonstrating confusion state that this is not the client's usual
behavior. How should the nurse document this data?
1. Inference
2. Subjective data
3. Objective data
4. Secondary subjective data - ANSWERSCorrect Answer: 3
The nurse provides a back rub to a client after administering a pain medication with the
hope that these two actions will help decrease the client's pain. Which phase of the
nursing process is this nurse implementing?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation - ANSWERSCorrect Answer: 3
A new client has been admitted to the care area. How soon should the nurse plan to
complete a physical assessment on this patient?
1. 1 hour
2. 12 hours
, 3. 48 hours
4. 24 hours - ANSWERSCorrect Answer: 4
The nurse is admitting an infant to the care area. The parents and grandmother are
present. What should the nurse use as the best source of data for this client?
1. Medical record from the child's birth
2. Grandmother
3. Parents
4. Admitting physician - ANSWERSCorrect Answer: 3
A newly admitted client is angry because nursing staff continue to ask the same
questions. What should the nurse respond to this client?
1. "In order to make sure all of your information is complete, I need to ask these
questions."
2. "You're right. Let me know if there's anything you need right now."
3. "I'll be done shortly, just give me a few more minutes."
4. "You shouldn't be upset. We're only doing our jobs." - ANSWERSCorrect Answer: 2
The nurse documents: "Client avoids eye contact and gives only vague, nonspecific
answers to direct questioning by the professional staff. Is quite animated (laughs aloud,
smiles, uses hand gestures) in conversation with spouse." Which method of data
collection does this documentation demonstrate?
1. Examining
2. Interviewing
3. Listening
4. Observing - ANSWERSCorrect Answer: 4
A nurse has worked in the trauma critical care area for several years. Which noise may
become indiscriminate for this particular nurse?
1. A client with audible breathing
2. Moaning of a client in pain
3. Whirring of ventilators
4. Co-orkers discussing their clients' conditions - ANSWERSCorrect Answer: 3
A client has been using the call light routinely throughout the evening. Upon entering
the room, the nurse observes the following details. Organize them according to priority
sequencing (1 is first priority; 5 is least priority).
Standard Text: Click and drag the options below to move them up or down.
Choice 1. The family is at the bedside.
Choice 2. The IV pump is running on battery.
Choice 3. The ECG monitor shows tachycardia.
Choice 4. The client reports being restless.
Choice 5. O2 tubing is not attached to wall regulator. - ANSWERSCorrect Answer: 3, 4,
5, 2, 1
