Nursing Process Questions-NUR 102 exam d d d d
The nurse in charge identifies a patient's responses to actual or potential health problems
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during which step of the nursing process? - answer-Diagnosis: The nurse identifies
d d d d d d d d d d d d
human responses to actual or potential health problems during the nursing diagnoses
d d d d d d d d d d d d
step of the nursing process. During the assessment step, the nurse collects data. During
d d d d d d d d d d d d d d
the planning step, the nurse develops strategies to resolve or decrease the patient's
d d d d d d d d d d d d d
problem. During evaluation, the nurse determines the effectiveness of the plan of care
d d d d d d d d d d d d d
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should
d d d d d d d d d d d
receive the highest priority at this time?
d d d d d d d
A. Impaired gas exchange related to increased blood flow
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B. Fluid volume excess related to peripheral vascular disease
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C. Risk for injury related to edema
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D. Altered peripheral tissue perfusion related to venous congestion - answer-D:
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(Rationale: This answer takes highest priority because venous inflammation and clot
d d d d d d d d d d d
formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect
d d d d d d d d d d d d d d
because impaired gas exchange is related to decreased, not increased, blood flow.
d d d d d d d d d d d d
Option B is inappropriate because no evidence suggests that this patient has a fluid
d d d d d d d d d d d d d d
volume excess. Option C may be warranted but is secondary to altered tissue perfusion)
d d d d d d d d d d d d d d
A nurse is revising a client's care plan. During which step of the nursing process does
d d d d d d d d d d d d d d d
such a revision take place?A. AssessmentB. PlanningC. Implementation D. Evaluation -
d d d d d d d d d d d
answer-D: (Rationale: During the evaluation step of the nursing process the nurse
d d d d d d d d d d d d
determines whether the goals established have been achieved, and evaluates the
d d d d d d d d d d d
success of the plan. Answer A involves data collection. Answer B involves setting
d d d d d d d d d d d d d
priorities, and Answer C is the actual intervention
d d d d d d d d
Which intervention should the nurse in charge try first for a client that exhibits signs of
d d d d d d d d d d d d d d d
sleep disturbance?A. Administer sleeping medication before bedtimeB. Ask the client
d d d d d d d d d d
each morning to describe the quantity of sleep the night beforeC. Teach the client
d d d d d d d d d d d d d d
relaxation techniques, such as guided imagery and progressive muscle relaxationD.
d d d d d d d d d d
Provide the client normal sleep aids, such as pillows, back rubs, and snacks - answer-D-
d d d d d d d d d d d d d d d
You should begin with the simplest interventions. Answer A is incorrect because
d d d d d d d d d d d
medications should be avoided whenever possible. Answer B would be a thorough sleep
d d d d d d d d d d d d d
assessment, and should be done only after common sense interventions fail. Answer C
d d d d d d d d d d d d d
would be appropriate only after common sense interventions fail.)
d d d d d d d d d
A nurse is assigned to care for a postoperative male client who has diabetes mellitus.
d d d d d d d d d d d d d d
During the assessment interview, the client reports that he's impotent and says he's
d d d d d d d d d d d d d
,d concerned about the effect on his marriage. In planning this client's care, the most
d d d d d d d d d d d d d
d appropriate intervention would be to:A. Encourage the client to ask questions about
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d personal sexualityB. Provide time for privacyC. Suggest referral to a sex counselor or
d d d d d d d d d d d d
d other appropriate professionalD. Provide support for the spouse - answer-C-Making
d d d d d d d d d
d appropriate referrals is a valid part of planning the client's care. The nurse normally does
d d d d d d d d d d d d d d
d not provide sex counseling. While providing time for privacy and providing support for the
d d d d d d d d d d d d d
d spouse is important, it is not as important as referring the client to a sex
d d d d d d d d d d d d d d
d counselor/appropriate professional) d
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client
d d d d d d d d d d d d d
need?A. Elimination B. Security C. SafetyD. Belonging - answer-A. According to Maslow,
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elimination is a first-level or physiological need. Security and safety are second-level
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needs, and belonging is a third-level need.)
d d d d d d d
A female client who received general anesthesia returns from surgery. Postoperatively,
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which nursing diagnosis takes highest priority for this client?A. Risk for aspiration R/T
d d d d d d d d d d d d d
anesthesia B. Deficient fluid volume R/T blood and fluid loss from surgery C. Impaired
d d d d d d d d d d d d d d
physical mobility R/T surgery D. Acute pain R/T surgery - answer-A. Risk for aspiration
d d d d d d d d d d d d d d
takes priority because general anesthesia may impair gag and swallow reflexes. The
d d d d d d d d d d d d
other options, although important, are secondary to this
d d d d d d d d
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle
d d d d d d d d d d d d d d d
accident. The first nursing priority for this client would be to:A. Assess the client's airway
d d d d d d d d d d d d d d d
B. Provide pain relief C. Encourage deep breathing and coughing D. Splint the chest wall
d d d d d d d d d d d d d d d
with a pillow - answer-A. (Rationale- The first priority is to evaluate airway patency. Pain
d d d d d d d d d d d d d d d
management and splinting are important for client comfort, but come after an airway
d d d d d d d d d d d d d
assessment. Coughing and deep breathing may be contraindicated if the client has
d d d d d d d d d d d d
internal bleeding and other injuries.)
d d d d d
When two nursing diagnoses appear closely related, what should the nurse do first to
d d d d d d d d d d d d d
determine which diagnosis most accurately reflects the needs of a patient?A. Reassess
d d d d d d d d d d d d
the patientB. Examine the related to factorsC. Review the defining characteristics,D.
d d d d d d d d d d d
Analyze the secondary to factors - answer-C: Rationale- The first thing a nurse should do
d d d d d d d d d d d d d d d
to differentiate is to compare the data collected to the major and minor defining
d d d d d d d d d d d d d d
characteristics of each of the nursing diagnoses being considered.)
d d d d d d d d d
The nurse performs an assessment of a newly admitted patient. The nurse understands
d d d d d d d d d d d d
that this admission assessment is conducted primarily to:A. Diagnose if the patient is at
d d d d d d d d d d d d d d
risk for falls.B. Identify important dataC. Establish a therapeutic relationshipD. Ensure
d d d d d d d d d d d
that the patient's skin is intact - answer-B: (Rationale- This is the primary purpose of a
d d d d d d d d d d d d d d d d
nursing admission assessment.)
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The guidelines for writing an appropriate nursing diagnosis include all of the following
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except: A. State the diagnosis in terms of a problem, not a need B. Use nursing
d d d d d d d d d d d d d d d d
terminology to describe the patient's response C. Use statements that assist in planning
d d d d d d d d d d d d d
independent nursing interventions D. Use medical terminology to describe the probable
d d d d d d d d d d d
, d cause of the patient's response - answer-D (Rationale- A nursing diagnosis is a statement
d d d d d d d d d d d d d
d about a patient's actual or potential health problem that is within the scope of independent
d d d d d d d d d d d d d d
d nursing intervention. Medical terminology is never part of the nursing diagnosis.)
d d d d d d d d d d
Independent nursing interventions commonly used for immobilized patients include all of
d d d d d d d d d d
dthe following except:A. Active or passive ROM exercises, body repositioning, and ADLs
d d d d d d d d d d d
das tolerated B. Deep-breathing and coughing exercises with change of position every 2
d d d d d d d d d d d d
dhoursC. Diaphragmatic and abdominal breathing exercisesD. Weight bearing on a tilt
d d d d d d d d d d
dtable, total parenteral nutrition, and vitamin therapy - answer-(Answer: ) D(Rationale- A,
d d d d d d d d d d d
dB, & C are incorrect. These are not independent nursing interventions because they
d d d d d d d d d d d d
drequire a physician's order.) d d d
Independent nursing interventions commonly used for patients with pressure ulcers d d d d d d d d d
dinclude:A. changing the patient's position regularly to minimize pressureB. Applying a
d d d d d d d d d d
ddrying agent such as an antacid to decrease moisture at the ulcer siteC. Debriding the
d d d d d d d d d d d d d d
dulcer to remove necrotic tissue, which can impede healingD. Placing the patient in a
d d d d d d d d d d d d d
dwhirlpool bath containing povidone-iodine solution as tolerated - answer-(Answer: )
d d d d d d d d d
dA(Rationale- Independent nursing interventions for a patient with pressure ulcersd d d d d d d d d
dcommonly include changing positions. B, C, & D all require a physician's order.
d d d d d d d d d d d d
dAdditionally, a drying agent, answer B would be contraindicated because the wound
d d d d d d d d d d d
dneeds moisture to heal.) d d d
While the nurse is providing a patient personal hygiene, she observes that his skin is
d d d d d d d d d d d d d d
excessively dry. During the procedure, he tells her that he is very thirsty. An appropriate
d d d d d d d d d d d d d d d
nursing diagnosis would be:A. Potential for impaired skin integrity R/T altered gland
d d d d d d d d d d d d
functionB. Potential for impaired skin integrity R/T dehydrationC. Impaired skin integrity
d d d d d d d d d d d
R/T dehydration D. Impaired skin integrity R/T altered circulation - answer-(Answer: )
d d d d d d d d d d d d
C(Rationale- The appropriate diagnosis for a patient with excessively dry skin is impaired
d d d d d d d d d d d d d
skin integrity - actual not potential. R/T dehydration is appropriate because the patient
d d d d d d d d d d d d d
complained of thirst.)
d d d
The most important nursing intervention to correct skin dryness is:A. avoid bathing until
d d d d d d d d d d d d
the condition is remedied and notify physicianB. ask physician to refer the patient to a
d d d d d d d d d d d d d d d
dermatologist C. Consult the dietitian about increasing fat intake, and take necessary
d d d d d d d d d d d d
measures to prevent infectionD. encourage the patient to increase fluid intake, use
d d d d d d d d d d d d
nonirritating soap, and apply lotion to involved areas - answer-(Answer: ) D(Rationale-
d d d d d d d d d d d d
Preventative measures, such as these, will prevent the skin from cracking, which would
d d d d d d d d d d d d d
make the client more prone to infection. The other 3 answers are options, however NOT
d d d d d d d d d d d d d d d
the best choice for this particular situation.)
d d d d d d d
Which of the following is an appropriately written nursing diagnosis? A) Pain related to
d d d d d d d d d d d d d
insufficient use of medication B) Pain related to difficulty ambulatingC) Anxiety related to
d d d d d d d d d d d d d
cardiac monitorD) Bedpan required frequently as a result of altered elimination pattern -
d d d d d d d d d d d d d
answer-(Answer: ) A (Rationale- A. This is an example of an appropriately written nursing
d d d d d d d d d d d d d d
diagnosis. It consists of a diagnostic label and the associated etiology. Nursing
d d d d d d d d d d d d
interventions can be directed at treating or managing the behavior of insufficient
d d d d d d d d d d d d
The nurse in charge identifies a patient's responses to actual or potential health problems
d d d d d d d d d d d d d
during which step of the nursing process? - answer-Diagnosis: The nurse identifies
d d d d d d d d d d d d
human responses to actual or potential health problems during the nursing diagnoses
d d d d d d d d d d d d
step of the nursing process. During the assessment step, the nurse collects data. During
d d d d d d d d d d d d d d
the planning step, the nurse develops strategies to resolve or decrease the patient's
d d d d d d d d d d d d d
problem. During evaluation, the nurse determines the effectiveness of the plan of care
d d d d d d d d d d d d d
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should
d d d d d d d d d d d
receive the highest priority at this time?
d d d d d d d
A. Impaired gas exchange related to increased blood flow
d d d d d d d d
B. Fluid volume excess related to peripheral vascular disease
d d d d d d d d
C. Risk for injury related to edema
d d d d d d
D. Altered peripheral tissue perfusion related to venous congestion - answer-D:
d d d d d d d d d d
(Rationale: This answer takes highest priority because venous inflammation and clot
d d d d d d d d d d d
formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect
d d d d d d d d d d d d d d
because impaired gas exchange is related to decreased, not increased, blood flow.
d d d d d d d d d d d d
Option B is inappropriate because no evidence suggests that this patient has a fluid
d d d d d d d d d d d d d d
volume excess. Option C may be warranted but is secondary to altered tissue perfusion)
d d d d d d d d d d d d d d
A nurse is revising a client's care plan. During which step of the nursing process does
d d d d d d d d d d d d d d d
such a revision take place?A. AssessmentB. PlanningC. Implementation D. Evaluation -
d d d d d d d d d d d
answer-D: (Rationale: During the evaluation step of the nursing process the nurse
d d d d d d d d d d d d
determines whether the goals established have been achieved, and evaluates the
d d d d d d d d d d d
success of the plan. Answer A involves data collection. Answer B involves setting
d d d d d d d d d d d d d
priorities, and Answer C is the actual intervention
d d d d d d d d
Which intervention should the nurse in charge try first for a client that exhibits signs of
d d d d d d d d d d d d d d d
sleep disturbance?A. Administer sleeping medication before bedtimeB. Ask the client
d d d d d d d d d d
each morning to describe the quantity of sleep the night beforeC. Teach the client
d d d d d d d d d d d d d d
relaxation techniques, such as guided imagery and progressive muscle relaxationD.
d d d d d d d d d d
Provide the client normal sleep aids, such as pillows, back rubs, and snacks - answer-D-
d d d d d d d d d d d d d d d
You should begin with the simplest interventions. Answer A is incorrect because
d d d d d d d d d d d
medications should be avoided whenever possible. Answer B would be a thorough sleep
d d d d d d d d d d d d d
assessment, and should be done only after common sense interventions fail. Answer C
d d d d d d d d d d d d d
would be appropriate only after common sense interventions fail.)
d d d d d d d d d
A nurse is assigned to care for a postoperative male client who has diabetes mellitus.
d d d d d d d d d d d d d d
During the assessment interview, the client reports that he's impotent and says he's
d d d d d d d d d d d d d
,d concerned about the effect on his marriage. In planning this client's care, the most
d d d d d d d d d d d d d
d appropriate intervention would be to:A. Encourage the client to ask questions about
d d d d d d d d d d d
d personal sexualityB. Provide time for privacyC. Suggest referral to a sex counselor or
d d d d d d d d d d d d
d other appropriate professionalD. Provide support for the spouse - answer-C-Making
d d d d d d d d d
d appropriate referrals is a valid part of planning the client's care. The nurse normally does
d d d d d d d d d d d d d d
d not provide sex counseling. While providing time for privacy and providing support for the
d d d d d d d d d d d d d
d spouse is important, it is not as important as referring the client to a sex
d d d d d d d d d d d d d d
d counselor/appropriate professional) d
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client
d d d d d d d d d d d d d
need?A. Elimination B. Security C. SafetyD. Belonging - answer-A. According to Maslow,
d d d d d d d d d d d d
elimination is a first-level or physiological need. Security and safety are second-level
d d d d d d d d d d d d
needs, and belonging is a third-level need.)
d d d d d d d
A female client who received general anesthesia returns from surgery. Postoperatively,
d d d d d d d d d d
which nursing diagnosis takes highest priority for this client?A. Risk for aspiration R/T
d d d d d d d d d d d d d
anesthesia B. Deficient fluid volume R/T blood and fluid loss from surgery C. Impaired
d d d d d d d d d d d d d d
physical mobility R/T surgery D. Acute pain R/T surgery - answer-A. Risk for aspiration
d d d d d d d d d d d d d d
takes priority because general anesthesia may impair gag and swallow reflexes. The
d d d d d d d d d d d d
other options, although important, are secondary to this
d d d d d d d d
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle
d d d d d d d d d d d d d d d
accident. The first nursing priority for this client would be to:A. Assess the client's airway
d d d d d d d d d d d d d d d
B. Provide pain relief C. Encourage deep breathing and coughing D. Splint the chest wall
d d d d d d d d d d d d d d d
with a pillow - answer-A. (Rationale- The first priority is to evaluate airway patency. Pain
d d d d d d d d d d d d d d d
management and splinting are important for client comfort, but come after an airway
d d d d d d d d d d d d d
assessment. Coughing and deep breathing may be contraindicated if the client has
d d d d d d d d d d d d
internal bleeding and other injuries.)
d d d d d
When two nursing diagnoses appear closely related, what should the nurse do first to
d d d d d d d d d d d d d
determine which diagnosis most accurately reflects the needs of a patient?A. Reassess
d d d d d d d d d d d d
the patientB. Examine the related to factorsC. Review the defining characteristics,D.
d d d d d d d d d d d
Analyze the secondary to factors - answer-C: Rationale- The first thing a nurse should do
d d d d d d d d d d d d d d d
to differentiate is to compare the data collected to the major and minor defining
d d d d d d d d d d d d d d
characteristics of each of the nursing diagnoses being considered.)
d d d d d d d d d
The nurse performs an assessment of a newly admitted patient. The nurse understands
d d d d d d d d d d d d
that this admission assessment is conducted primarily to:A. Diagnose if the patient is at
d d d d d d d d d d d d d d
risk for falls.B. Identify important dataC. Establish a therapeutic relationshipD. Ensure
d d d d d d d d d d d
that the patient's skin is intact - answer-B: (Rationale- This is the primary purpose of a
d d d d d d d d d d d d d d d d
nursing admission assessment.)
d d d
The guidelines for writing an appropriate nursing diagnosis include all of the following
d d d d d d d d d d d d
except: A. State the diagnosis in terms of a problem, not a need B. Use nursing
d d d d d d d d d d d d d d d d
terminology to describe the patient's response C. Use statements that assist in planning
d d d d d d d d d d d d d
independent nursing interventions D. Use medical terminology to describe the probable
d d d d d d d d d d d
, d cause of the patient's response - answer-D (Rationale- A nursing diagnosis is a statement
d d d d d d d d d d d d d
d about a patient's actual or potential health problem that is within the scope of independent
d d d d d d d d d d d d d d
d nursing intervention. Medical terminology is never part of the nursing diagnosis.)
d d d d d d d d d d
Independent nursing interventions commonly used for immobilized patients include all of
d d d d d d d d d d
dthe following except:A. Active or passive ROM exercises, body repositioning, and ADLs
d d d d d d d d d d d
das tolerated B. Deep-breathing and coughing exercises with change of position every 2
d d d d d d d d d d d d
dhoursC. Diaphragmatic and abdominal breathing exercisesD. Weight bearing on a tilt
d d d d d d d d d d
dtable, total parenteral nutrition, and vitamin therapy - answer-(Answer: ) D(Rationale- A,
d d d d d d d d d d d
dB, & C are incorrect. These are not independent nursing interventions because they
d d d d d d d d d d d d
drequire a physician's order.) d d d
Independent nursing interventions commonly used for patients with pressure ulcers d d d d d d d d d
dinclude:A. changing the patient's position regularly to minimize pressureB. Applying a
d d d d d d d d d d
ddrying agent such as an antacid to decrease moisture at the ulcer siteC. Debriding the
d d d d d d d d d d d d d d
dulcer to remove necrotic tissue, which can impede healingD. Placing the patient in a
d d d d d d d d d d d d d
dwhirlpool bath containing povidone-iodine solution as tolerated - answer-(Answer: )
d d d d d d d d d
dA(Rationale- Independent nursing interventions for a patient with pressure ulcersd d d d d d d d d
dcommonly include changing positions. B, C, & D all require a physician's order.
d d d d d d d d d d d d
dAdditionally, a drying agent, answer B would be contraindicated because the wound
d d d d d d d d d d d
dneeds moisture to heal.) d d d
While the nurse is providing a patient personal hygiene, she observes that his skin is
d d d d d d d d d d d d d d
excessively dry. During the procedure, he tells her that he is very thirsty. An appropriate
d d d d d d d d d d d d d d d
nursing diagnosis would be:A. Potential for impaired skin integrity R/T altered gland
d d d d d d d d d d d d
functionB. Potential for impaired skin integrity R/T dehydrationC. Impaired skin integrity
d d d d d d d d d d d
R/T dehydration D. Impaired skin integrity R/T altered circulation - answer-(Answer: )
d d d d d d d d d d d d
C(Rationale- The appropriate diagnosis for a patient with excessively dry skin is impaired
d d d d d d d d d d d d d
skin integrity - actual not potential. R/T dehydration is appropriate because the patient
d d d d d d d d d d d d d
complained of thirst.)
d d d
The most important nursing intervention to correct skin dryness is:A. avoid bathing until
d d d d d d d d d d d d
the condition is remedied and notify physicianB. ask physician to refer the patient to a
d d d d d d d d d d d d d d d
dermatologist C. Consult the dietitian about increasing fat intake, and take necessary
d d d d d d d d d d d d
measures to prevent infectionD. encourage the patient to increase fluid intake, use
d d d d d d d d d d d d
nonirritating soap, and apply lotion to involved areas - answer-(Answer: ) D(Rationale-
d d d d d d d d d d d d
Preventative measures, such as these, will prevent the skin from cracking, which would
d d d d d d d d d d d d d
make the client more prone to infection. The other 3 answers are options, however NOT
d d d d d d d d d d d d d d d
the best choice for this particular situation.)
d d d d d d d
Which of the following is an appropriately written nursing diagnosis? A) Pain related to
d d d d d d d d d d d d d
insufficient use of medication B) Pain related to difficulty ambulatingC) Anxiety related to
d d d d d d d d d d d d d
cardiac monitorD) Bedpan required frequently as a result of altered elimination pattern -
d d d d d d d d d d d d d
answer-(Answer: ) A (Rationale- A. This is an example of an appropriately written nursing
d d d d d d d d d d d d d d
diagnosis. It consists of a diagnostic label and the associated etiology. Nursing
d d d d d d d d d d d d
interventions can be directed at treating or managing the behavior of insufficient
d d d d d d d d d d d d
