NCLEX QUESTIONS: NURSING PROCESS
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."
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 - ansC. Do the interview as soon as some uninterrupted time is available in order to
address the client's concerns
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
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 - ansD. Nurse rapidly
reset priorities for client care based on a change in the client's condition
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 - ansA. Return demonstration
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 - ansA. Introduction
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 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."
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 - ansC. Do the interview as soon as some uninterrupted time is available in order to
address the client's concerns
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
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 - ansD. Nurse rapidly
reset priorities for client care based on a change in the client's condition
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 - ansA. Return demonstration
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 - ansA. Introduction
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?
