PRACTICE QUESTIONS
1. A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due to
multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in
the nursing process? Select all that apply.
a. The nurse uses the nursing interview to collect patient data.
b. The nurse analyzes data collected in the nursing assessment.
c. The nurse develops a care plan for the patient.
d. The nurse points out the patient's strengths.
e. The nurse assesses the patient's mental status.
f. The nurse identifies community resources to help his family cope.
ANSWERS - b. The nurse analyzes data collected in the nursing assessment.
d. The nurse points out the patient's strengths.
f. The nurse identifies community resources to help his family cope.
2. A nurse is caring for an older adult patient who presents with labored respirations, productive
cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that
apply.
a. Bronchial pneumonia
b. Impaired gas exchange
, c. Ineffective airway clearance
d. Potential complication: sepsis
e. Infection related to pneumonia
f. Risk for septic shock
ANSWERS - b. Impaired gas exchange
c. Ineffective airway clearance
f. Risk for septic shock
3. After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse
interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached
when identifying the need to collect more data to confirm a diagnosis of situational low self-
esteem?
a. No problem
b. Possible problem
c. Actual nursing diagnosis
d. Clinical problem other than nursing diagnosis.
ANSWER - b. Possible problem
4. A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired
Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels
and back. Which phrase represents the etiology of this diagnostic statement?