- ans
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." - ansD. 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 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 - ansC. 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.
For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts,
what is the major related factor or risk factor identified by the nurse?
A. Discomfort
B. Deficit
C. Feeding
D. Fractured wrists - ansD. Fractured Wrists
Rationale: The etiology or related factors of a nursing diagnostic statement define one or more probable causes
of the problem and allow the nurse to individualize the client's care. In this case, the fracture is the cause of the
client's feeding problem.
The client reports nausea and constipation. Which of the following would be the priority nursing action?
A. Collect a stool sample
B. Complete an abnormal assessment
C. Administer an anti-nausea medication
D. Notify the physician - ansB. Complete an Abdominal assessment
Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent
phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body
system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other
options reflect interventions, which are not timely unless there is first a complete assessment.
The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be
transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time?
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." - ansD. 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 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 - ansC. 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.
For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts,
what is the major related factor or risk factor identified by the nurse?
A. Discomfort
B. Deficit
C. Feeding
D. Fractured wrists - ansD. Fractured Wrists
Rationale: The etiology or related factors of a nursing diagnostic statement define one or more probable causes
of the problem and allow the nurse to individualize the client's care. In this case, the fracture is the cause of the
client's feeding problem.
The client reports nausea and constipation. Which of the following would be the priority nursing action?
A. Collect a stool sample
B. Complete an abnormal assessment
C. Administer an anti-nausea medication
D. Notify the physician - ansB. Complete an Abdominal assessment
Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent
phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body
system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other
options reflect interventions, which are not timely unless there is first a complete assessment.
The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be
transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time?
