NCLEX QUESTIONS: NURSING PROCESS, NURSING
PROCESS NCLEX PRACTICE QUESTIONS
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 - Answers -A. Introduction
Rationale: Asking about the weather initiates the social or introductory phase of the
interview and allows the nurse to begin an assessment of the client's mental status. The
goal is to develop rapport with the client at the beginning of the interview. In the body
the client responds to the nurse's questions. During the closing the nurse or the client
terminates the interview.
The nurse is most likely to collect timely, specific information by asking which of the
following questions?
A. "Would you describe what you are feeling?"
B. "How are you today?"
C. "What would you like to talk about?"
D. "Where does it hurt?" - Answers -A. "Would you describe what you are feeling?"
Rationale: This is an open-ended question that will elicit subjective data. The data
collected will reflect the client's current health status and human response(s) and should
generate specific information that can be used to identify actual and/or potential health
problems. Options 2 and 3 are more likely to elicit general, nonspecific information.
Option 4 may result in a brief, one-word response or nonverbal gesture indicating the
site of the client's pain. A better approach to collect specific information might be,
"Describe any pain you are having."
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 - Answers -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.
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 - Answers -B. 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 suspects that a client is withholding health-related information out of fear of
discovery and possible legal problems. The nurse formulates nursing diagnoses for the
client carefully, being concerned about a diagnostic error resulting from which of the
following?
A. Incomplete data
B. Generalize from experience
C. Identifying with the client
D. Lack of clinical experience - Answers -A. Incomplete data
Rationale: To collect data accurately, the client must actively participate. Incomplete
data can lead to inappropriate nursing diagnosis and planning. The other options are
not relevant to the question as presented.
The nurse should avoid asking the client which of the following leading questions during
a client interview?
A. "What medication do you take at home?"
B. "You are really excited about the plastic surgery, aren't you?"
C. "Were you aware I've has this same type of surgery?"
D. "What would you like to talk about?" - Answers -B. "You are really excited about the
plastic surgery, aren't you?"
Rationale: A leading question directs the client's answer. The phrasing of the question
indicates an expected answer. The client may be influenced by the nurse's expectations
and may give inaccurate responses. This process can result in an error in diagnostic
reasoning.
PROCESS NCLEX PRACTICE QUESTIONS
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 - Answers -A. Introduction
Rationale: Asking about the weather initiates the social or introductory phase of the
interview and allows the nurse to begin an assessment of the client's mental status. The
goal is to develop rapport with the client at the beginning of the interview. In the body
the client responds to the nurse's questions. During the closing the nurse or the client
terminates the interview.
The nurse is most likely to collect timely, specific information by asking which of the
following questions?
A. "Would you describe what you are feeling?"
B. "How are you today?"
C. "What would you like to talk about?"
D. "Where does it hurt?" - Answers -A. "Would you describe what you are feeling?"
Rationale: This is an open-ended question that will elicit subjective data. The data
collected will reflect the client's current health status and human response(s) and should
generate specific information that can be used to identify actual and/or potential health
problems. Options 2 and 3 are more likely to elicit general, nonspecific information.
Option 4 may result in a brief, one-word response or nonverbal gesture indicating the
site of the client's pain. A better approach to collect specific information might be,
"Describe any pain you are having."
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 - Answers -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.
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 - Answers -B. 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 suspects that a client is withholding health-related information out of fear of
discovery and possible legal problems. The nurse formulates nursing diagnoses for the
client carefully, being concerned about a diagnostic error resulting from which of the
following?
A. Incomplete data
B. Generalize from experience
C. Identifying with the client
D. Lack of clinical experience - Answers -A. Incomplete data
Rationale: To collect data accurately, the client must actively participate. Incomplete
data can lead to inappropriate nursing diagnosis and planning. The other options are
not relevant to the question as presented.
The nurse should avoid asking the client which of the following leading questions during
a client interview?
A. "What medication do you take at home?"
B. "You are really excited about the plastic surgery, aren't you?"
C. "Were you aware I've has this same type of surgery?"
D. "What would you like to talk about?" - Answers -B. "You are really excited about the
plastic surgery, aren't you?"
Rationale: A leading question directs the client's answer. The phrasing of the question
indicates an expected answer. The client may be influenced by the nurse's expectations
and may give inaccurate responses. This process can result in an error in diagnostic
reasoning.
