1. A client reports to a health care facility with complaints of abdominal pain and
vomiting. The client's wife informs the nurse that the client had gone out for dinner the
previous night. Which of the following would be the primary source of assessment data?
A) Client's friends
B) Client's wife
C) Client himself
D) Test reports
Ans: C
Feedback:
As the client is in a conscious state, he himself is the primary source of information
since he can give firsthand information. The client's wife, friends, and test results would
be the secondary sources of data.
2. A client with HIV has been admitted to a health care facility. Which of the following
nursing diagnoses should be of the highest priority, keeping in mind the client's
condition?
A) Risk for activity intolerance
B) Risk for ineffective coping
C) Risk for infection
D) Risk for imbalanced nutrition
Ans: C
Feedback:
Clients with HIV have decreased immunity and are prone to infections. Infection in a
client with HIV is life-threatening, because it makes the client vulnerable to other
infections, and also impairs his or her already weakened immune functions. Clients with
HIV may not have problems with other activities and food. They may often feel
depressed, but this is not the highest priority.
3. A client is being prepared for cardiac catheterization. The nurse performs an initial
assessment and records the vital signs. Which of the following data collected can be
classified as subjective data?
A) Blood pressure
B) Nausea
C) Heart rate
D) Respiratory rate
Ans: B
Feedback:
Subjective data are those that the client can feel and describe. Nausea is subjective data,
as it can only be described and not measured. Blood pressure, heart rate, and respiratory
rate are measurable factors and are therefore objective data.
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, 4. A #ngclient #ngwho #nghas #ngto #ngundergo #nga #ngthyroidectomy #ngis #ngworried #ngthat #nghe #ngmay
#nghave #ngto #ngwear #nga #ngscarf #ngaround #nghis #ngneck #ngafter #ngsurgery. #ngWhat #ngnursing
#ngdiagnosis #ngshould #ngthe #ngnurse #ngdocument
in #ngthe #ngcare #ngplan?
A) Risk #ngfor #ngimpaired #ngphysical #ngmobility #ngdue #ngto #ngsurgery
B) Ineffective #ngdenial #ngrelated #ngto #ngpoor #ngcoping #ngmechanisms
C) Disturbed #ngbody #ngimage #ngrelated #ngto #ngthe #ngincision #ngscar
D) Risk #ngof #nginjury #ngrelated #ngto #ngsurgical #ngoutcomes
Ans: C
Feedback:
The #ngclient #ngis #ngconcerned #ngabout #ngthe #ngsurgery #ngscar #ngon #nghis #ngneck, #ngwhich #ngwould
#ngdisturb #nghis #ngbody #ngimage; #ngtherefore, #ngthe #ngappropriate #ngdiagnosis #ngshould #ngbe
#ngdisturbed #ngbody #ngimage #ngrelated #ngto #ngthe #ngincision #ngscar. #ngRisk #ngfor #ngimpaired
#ngphysical #ngmobility #ngmay #ngbe #ngpresent #ngafter #ngsurgery, #ngbut #ngis #ngnot #ngrelated #ngto #ngthe
#ngconcerns #ngexpressed #ngby #ngthe #ngclient. #ngLikewise, #ngineffective #ngdenial
related #ngto #ngpoor #ngcoping #ngmechanisms #ngand #nginjury #ngrelated #ngto #ngsurgical #ngoutcomes
#ngare #ngalso #ngnot #ngrelated #ngto #ngthe #ngclient's #ngconcern.
5. A #ngnurse #ngis #nggiving #ngpostoperative #ngcare #ngto #nga #ngclient #ngafter #ngknee #ngarthroplasty.
#ngWhich #ngof #ngthe
following #ngis #nga #ngpossible #ngshort-term #nggoal #ngfor #ngthis #ngclient?
A) To #ngambulate #ngthe #ngclient #ngto #nga #ngbedside #ngchair
B) To #nghelp #ngthe #ngclient #ngreturn #ngto #ngactivities #ngof #ngdaily #nglife
C) To #ngmaintain #nga #nghealthy #ngand #ngactive #nglifestyle
D) To #ngprevent #ngrepeat #ngsurgery #ngin #ngthe #ngclient
Ans: A
Feedback:
The #ngshort-term #nggoal #ngin #ngthis #ngcase #ngis #ngto #nghelp #ngthe #ngclient #ngambulate #ngto #ngthe
#ngbedside #ngchair. #ngThe #ngother #nggoals, #ngsuch #ngas #nghelping #ngthe #ngclient #ngreturn #ngto
#ngactivities #ngof #ngdaily #nglife, #ngto #ngmaintain #nga #nghealthy #ngand #ngactive #nglifestyle, #ngand #ngto
#ngprevent #ngrepeat #ngsurgery #ngin #ngthe #ngclient #ngare #nglong-term
goals #ngand #ngmay #ngtake #ngweeks #ngor #ngmonths #ngto #ngachieve. #ngOn #ngthe #ngother #nghand, #ngshort-
term #nggoals #ngcan #ngbe #ngachieved #ngin #nga #ngday #ngor #nga #ngweek.
6. A #ngnurse #ngwho #ngis #ngcaring #ngfor #nga #ngclient #ngadmitted #ngto #ngthe #ngnursing #ngunit #ngwith #ngacute
#ngabdominal #ngpain #ngformulates #ngthe #ngcare #ngplan #ngfor #ngthe #ngclient. #ngWhich #ngof #ngthe
#ngfollowing #ngnursing #ngdiagnoses #ngis #ngthe
highest #ngpriority #ngfor #ngthis #ngclient?
A) Impaired #ngcomfort
B) Disturbed #ngbody #ngimage
C) Disturbed #ngsleep #ngpattern
D) Activity #ngintolerance
Ans: A
Feedback:
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SCHOLARVAULT
vomiting. The client's wife informs the nurse that the client had gone out for dinner the
previous night. Which of the following would be the primary source of assessment data?
A) Client's friends
B) Client's wife
C) Client himself
D) Test reports
Ans: C
Feedback:
As the client is in a conscious state, he himself is the primary source of information
since he can give firsthand information. The client's wife, friends, and test results would
be the secondary sources of data.
2. A client with HIV has been admitted to a health care facility. Which of the following
nursing diagnoses should be of the highest priority, keeping in mind the client's
condition?
A) Risk for activity intolerance
B) Risk for ineffective coping
C) Risk for infection
D) Risk for imbalanced nutrition
Ans: C
Feedback:
Clients with HIV have decreased immunity and are prone to infections. Infection in a
client with HIV is life-threatening, because it makes the client vulnerable to other
infections, and also impairs his or her already weakened immune functions. Clients with
HIV may not have problems with other activities and food. They may often feel
depressed, but this is not the highest priority.
3. A client is being prepared for cardiac catheterization. The nurse performs an initial
assessment and records the vital signs. Which of the following data collected can be
classified as subjective data?
A) Blood pressure
B) Nausea
C) Heart rate
D) Respiratory rate
Ans: B
Feedback:
Subjective data are those that the client can feel and describe. Nausea is subjective data,
as it can only be described and not measured. Blood pressure, heart rate, and respiratory
rate are measurable factors and are therefore objective data.
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SCHOLARVAULT
, 4. A #ngclient #ngwho #nghas #ngto #ngundergo #nga #ngthyroidectomy #ngis #ngworried #ngthat #nghe #ngmay
#nghave #ngto #ngwear #nga #ngscarf #ngaround #nghis #ngneck #ngafter #ngsurgery. #ngWhat #ngnursing
#ngdiagnosis #ngshould #ngthe #ngnurse #ngdocument
in #ngthe #ngcare #ngplan?
A) Risk #ngfor #ngimpaired #ngphysical #ngmobility #ngdue #ngto #ngsurgery
B) Ineffective #ngdenial #ngrelated #ngto #ngpoor #ngcoping #ngmechanisms
C) Disturbed #ngbody #ngimage #ngrelated #ngto #ngthe #ngincision #ngscar
D) Risk #ngof #nginjury #ngrelated #ngto #ngsurgical #ngoutcomes
Ans: C
Feedback:
The #ngclient #ngis #ngconcerned #ngabout #ngthe #ngsurgery #ngscar #ngon #nghis #ngneck, #ngwhich #ngwould
#ngdisturb #nghis #ngbody #ngimage; #ngtherefore, #ngthe #ngappropriate #ngdiagnosis #ngshould #ngbe
#ngdisturbed #ngbody #ngimage #ngrelated #ngto #ngthe #ngincision #ngscar. #ngRisk #ngfor #ngimpaired
#ngphysical #ngmobility #ngmay #ngbe #ngpresent #ngafter #ngsurgery, #ngbut #ngis #ngnot #ngrelated #ngto #ngthe
#ngconcerns #ngexpressed #ngby #ngthe #ngclient. #ngLikewise, #ngineffective #ngdenial
related #ngto #ngpoor #ngcoping #ngmechanisms #ngand #nginjury #ngrelated #ngto #ngsurgical #ngoutcomes
#ngare #ngalso #ngnot #ngrelated #ngto #ngthe #ngclient's #ngconcern.
5. A #ngnurse #ngis #nggiving #ngpostoperative #ngcare #ngto #nga #ngclient #ngafter #ngknee #ngarthroplasty.
#ngWhich #ngof #ngthe
following #ngis #nga #ngpossible #ngshort-term #nggoal #ngfor #ngthis #ngclient?
A) To #ngambulate #ngthe #ngclient #ngto #nga #ngbedside #ngchair
B) To #nghelp #ngthe #ngclient #ngreturn #ngto #ngactivities #ngof #ngdaily #nglife
C) To #ngmaintain #nga #nghealthy #ngand #ngactive #nglifestyle
D) To #ngprevent #ngrepeat #ngsurgery #ngin #ngthe #ngclient
Ans: A
Feedback:
The #ngshort-term #nggoal #ngin #ngthis #ngcase #ngis #ngto #nghelp #ngthe #ngclient #ngambulate #ngto #ngthe
#ngbedside #ngchair. #ngThe #ngother #nggoals, #ngsuch #ngas #nghelping #ngthe #ngclient #ngreturn #ngto
#ngactivities #ngof #ngdaily #nglife, #ngto #ngmaintain #nga #nghealthy #ngand #ngactive #nglifestyle, #ngand #ngto
#ngprevent #ngrepeat #ngsurgery #ngin #ngthe #ngclient #ngare #nglong-term
goals #ngand #ngmay #ngtake #ngweeks #ngor #ngmonths #ngto #ngachieve. #ngOn #ngthe #ngother #nghand, #ngshort-
term #nggoals #ngcan #ngbe #ngachieved #ngin #nga #ngday #ngor #nga #ngweek.
6. A #ngnurse #ngwho #ngis #ngcaring #ngfor #nga #ngclient #ngadmitted #ngto #ngthe #ngnursing #ngunit #ngwith #ngacute
#ngabdominal #ngpain #ngformulates #ngthe #ngcare #ngplan #ngfor #ngthe #ngclient. #ngWhich #ngof #ngthe
#ngfollowing #ngnursing #ngdiagnoses #ngis #ngthe
highest #ngpriority #ngfor #ngthis #ngclient?
A) Impaired #ngcomfort
B) Disturbed #ngbody #ngimage
C) Disturbed #ngsleep #ngpattern
D) Activity #ngintolerance
Ans: A
Feedback:
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