NURSING PROCESS/DIAGNOSES PRACTICE TEST
(NCLEX STYLE) 15 MULTIPLE CHOICE
The nurse in charge identifies a patient's responses to actual or potential health
problems during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating - Answers -Answer: B
Rationale- The nurse identifies human responses to actual or potential health problems
during the nursing diagnoses step of the nursing process. During the assessment step,
the nurse collects data. During the planning step, the nurse develops strategies to
resolve or decrease the patient's problem. During evaluation, the nurse determines the
effectiveness of the plan of care.
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis
should receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion - Answers -Answer:
D
Rationale: This answer takes highest priority because venous inflammation and clot
formation impede blood flow in a patient with deep-vein thrombosis.
Option A is incorrect because impaired gas exchange is related to decreased, not
increased, blood flow. Option B is inappropriate because no evidence suggests that this
patient has a fluid volume excess. Option C may be warranted but is secondary to
altered tissue perfusion
A female client who received general anesthesia returns from surgery. Postoperatively,
which nursing diagnosis takes highest priority for this client?
A. Acute pain R/T surgery
B. Deficient fluid volume R/T blood and fluid loss from surgery
C. Impaired physical mobility R/T surgery
D. Risk for aspiration R/T anesthesia - Answers -Answer: D
Rationale- Risk for aspiration takes priority because general anesthesia may impair gag
and swallow reflexes. The other options, although important, are secondary to this.
, A male client is admitted to the hospital with blunt chest trauma after a motor vehicle
accident. The first nursing priority for this client would be to:
A. Assess the client's airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow - Answers -Answer: A
Rationale- The first priority is to evaluate airway patency. Pain management and
splinting are important for client comfort, but come after an airway assessment.
Coughing and deep breathing may be contraindicated if the client has internal bleeding
and other injuries.
When two nursing diagnoses appear closely related, what should the nurse do first to
determine which diagnosis most accurately reflects the needs of a patient?
A. Reassess the patient
B. Examine the related to factors
C. Analyze the secondary to factors
D. Review the defining characteristics - Answers -Answer: D
Rationale- The first thing a nurse should do to differentiate is to compare the data
collected to the major and minor defining characteristics of each of the nursing
diagnoses being considered.
The nurse performs an assessment of a newly admitted patient. The nurse understands
that this admission assessment is conducted primarily to:
A. Diagnose if the patient is at risk for falls.
B. Ensure that the patient's skin is intact
C. Establish a therapeutic relationship
D. Identify important data - Answers -Answer: D
Rationale- This is the primary purpose of a nursing admission assessment.
The guidelines for writing an appropriate nursing diagnosis include all of the following
except:
A. State the diagnosis in terms of a problem, not a need
B. Use nursing terminology to describe the patient's response
C. Use statements that assist in planning independent nursing interventions
D. Use medical terminology to describe the probable cause of the patient's response -
Answers -Answer- D
(NCLEX STYLE) 15 MULTIPLE CHOICE
The nurse in charge identifies a patient's responses to actual or potential health
problems during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating - Answers -Answer: B
Rationale- The nurse identifies human responses to actual or potential health problems
during the nursing diagnoses step of the nursing process. During the assessment step,
the nurse collects data. During the planning step, the nurse develops strategies to
resolve or decrease the patient's problem. During evaluation, the nurse determines the
effectiveness of the plan of care.
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis
should receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion - Answers -Answer:
D
Rationale: This answer takes highest priority because venous inflammation and clot
formation impede blood flow in a patient with deep-vein thrombosis.
Option A is incorrect because impaired gas exchange is related to decreased, not
increased, blood flow. Option B is inappropriate because no evidence suggests that this
patient has a fluid volume excess. Option C may be warranted but is secondary to
altered tissue perfusion
A female client who received general anesthesia returns from surgery. Postoperatively,
which nursing diagnosis takes highest priority for this client?
A. Acute pain R/T surgery
B. Deficient fluid volume R/T blood and fluid loss from surgery
C. Impaired physical mobility R/T surgery
D. Risk for aspiration R/T anesthesia - Answers -Answer: D
Rationale- Risk for aspiration takes priority because general anesthesia may impair gag
and swallow reflexes. The other options, although important, are secondary to this.
, A male client is admitted to the hospital with blunt chest trauma after a motor vehicle
accident. The first nursing priority for this client would be to:
A. Assess the client's airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow - Answers -Answer: A
Rationale- The first priority is to evaluate airway patency. Pain management and
splinting are important for client comfort, but come after an airway assessment.
Coughing and deep breathing may be contraindicated if the client has internal bleeding
and other injuries.
When two nursing diagnoses appear closely related, what should the nurse do first to
determine which diagnosis most accurately reflects the needs of a patient?
A. Reassess the patient
B. Examine the related to factors
C. Analyze the secondary to factors
D. Review the defining characteristics - Answers -Answer: D
Rationale- The first thing a nurse should do to differentiate is to compare the data
collected to the major and minor defining characteristics of each of the nursing
diagnoses being considered.
The nurse performs an assessment of a newly admitted patient. The nurse understands
that this admission assessment is conducted primarily to:
A. Diagnose if the patient is at risk for falls.
B. Ensure that the patient's skin is intact
C. Establish a therapeutic relationship
D. Identify important data - Answers -Answer: D
Rationale- This is the primary purpose of a nursing admission assessment.
The guidelines for writing an appropriate nursing diagnosis include all of the following
except:
A. State the diagnosis in terms of a problem, not a need
B. Use nursing terminology to describe the patient's response
C. Use statements that assist in planning independent nursing interventions
D. Use medical terminology to describe the probable cause of the patient's response -
Answers -Answer- D
