1
NUR2058 Exam 2 2024/2025 –
Dimensions of Nursing
Practice | Rasmussen |
Updated and Verified Answer
Key
Nursing Process
1. A nurse is caring for a client with shortness of breath. What is the first step in the
nursing process?
A. Develop a care plan
B. Collect subjective and objective data
C. Implement interventions
D. Evaluate outcomes
Correct Answer: B. Collect subjective and objective data
Rationale: The nursing process begins with assessment, collecting subjective (client-
reported) and objective (measurable) data, such as respiratory rate and oxygen saturation,
to identify client needs.
2. Which nursing diagnosis is most appropriate for a client with a wound infection?
A. Risk for Falls
B. Impaired Skin Integrity
C. Deficient Fluid Volume
D. Ineffective Coping
Correct Answer: B. Impaired Skin Integrity
Rationale: Impaired Skin Integrity directly addresses the wound infection, reflecting the
client’s compromised skin barrier and guiding targeted interventions.
3. A nurse sets a goal for a client with chronic pain to "report pain less than 4/10."
Which phase of the nursing process is this?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
Correct Answer: C. Planning
, 2
Rationale: Planning involves setting measurable, client-centered goals, such as pain
reduction, to guide interventions and evaluate outcomes.
4. Select all that apply: Which actions are part of the implementation phase of the
nursing process?
A. Administering prescribed medications
B. Documenting vital signs
C. Identifying client health problems
D. Teaching self-care techniques
E. Setting client goals
Correct Answers: A. Administering prescribed medications, B. Documenting vital
signs, D. Teaching self-care techniques
Rationale: Implementation includes actions like administering medications,
documenting, and teaching. Identifying problems and setting goals occur in diagnosis and
planning phases.
5. A nurse evaluates that a client’s blood pressure remains high despite medication.
What is the next step?
A. Continue the same medication
B. Reassess and revise the care plan
C. Discontinue all interventions
D. Ignore the evaluation
Correct Answer: B. Reassess and revise the care plan
Rationale: Evaluation assesses intervention effectiveness. If goals are unmet (e.g., high
blood pressure), the nurse reassesses and revises the care plan to improve outcomes.
6. What is the purpose of the nursing process?
A. Replace medical diagnoses
B. Provide a systematic approach to client care
C. Limit nurse accountability
D. Prescribe medications
Correct Answer: B. Provide a systematic approach to client care
Rationale: The nursing process provides a systematic, client-centered framework to
assess, diagnose, plan, implement, and evaluate care, ensuring quality and consistency.
Therapeutic Communication
7. A client says, “I’m scared about my diagnosis.” What is the nurse’s best response?
A. “You don’t need to worry.”
B. “Can you share what’s scaring you?”
C. “It’s a common diagnosis.”
D. “Let’s discuss your treatment instead.”
Correct Answer: B. “Can you share what’s scaring you?”
Rationale: Open-ended questions encourage the client to express fears, fostering
therapeutic communication and addressing emotional needs.
8. A nurse is communicating with a client who is visually impaired. What is the most
effective strategy?
NUR2058 Exam 2 2024/2025 –
Dimensions of Nursing
Practice | Rasmussen |
Updated and Verified Answer
Key
Nursing Process
1. A nurse is caring for a client with shortness of breath. What is the first step in the
nursing process?
A. Develop a care plan
B. Collect subjective and objective data
C. Implement interventions
D. Evaluate outcomes
Correct Answer: B. Collect subjective and objective data
Rationale: The nursing process begins with assessment, collecting subjective (client-
reported) and objective (measurable) data, such as respiratory rate and oxygen saturation,
to identify client needs.
2. Which nursing diagnosis is most appropriate for a client with a wound infection?
A. Risk for Falls
B. Impaired Skin Integrity
C. Deficient Fluid Volume
D. Ineffective Coping
Correct Answer: B. Impaired Skin Integrity
Rationale: Impaired Skin Integrity directly addresses the wound infection, reflecting the
client’s compromised skin barrier and guiding targeted interventions.
3. A nurse sets a goal for a client with chronic pain to "report pain less than 4/10."
Which phase of the nursing process is this?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation
Correct Answer: C. Planning
, 2
Rationale: Planning involves setting measurable, client-centered goals, such as pain
reduction, to guide interventions and evaluate outcomes.
4. Select all that apply: Which actions are part of the implementation phase of the
nursing process?
A. Administering prescribed medications
B. Documenting vital signs
C. Identifying client health problems
D. Teaching self-care techniques
E. Setting client goals
Correct Answers: A. Administering prescribed medications, B. Documenting vital
signs, D. Teaching self-care techniques
Rationale: Implementation includes actions like administering medications,
documenting, and teaching. Identifying problems and setting goals occur in diagnosis and
planning phases.
5. A nurse evaluates that a client’s blood pressure remains high despite medication.
What is the next step?
A. Continue the same medication
B. Reassess and revise the care plan
C. Discontinue all interventions
D. Ignore the evaluation
Correct Answer: B. Reassess and revise the care plan
Rationale: Evaluation assesses intervention effectiveness. If goals are unmet (e.g., high
blood pressure), the nurse reassesses and revises the care plan to improve outcomes.
6. What is the purpose of the nursing process?
A. Replace medical diagnoses
B. Provide a systematic approach to client care
C. Limit nurse accountability
D. Prescribe medications
Correct Answer: B. Provide a systematic approach to client care
Rationale: The nursing process provides a systematic, client-centered framework to
assess, diagnose, plan, implement, and evaluate care, ensuring quality and consistency.
Therapeutic Communication
7. A client says, “I’m scared about my diagnosis.” What is the nurse’s best response?
A. “You don’t need to worry.”
B. “Can you share what’s scaring you?”
C. “It’s a common diagnosis.”
D. “Let’s discuss your treatment instead.”
Correct Answer: B. “Can you share what’s scaring you?”
Rationale: Open-ended questions encourage the client to express fears, fostering
therapeutic communication and addressing emotional needs.
8. A nurse is communicating with a client who is visually impaired. What is the most
effective strategy?
