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
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
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 nurse is revising a client's care
plan. During which step of the
nursing process does such a revision
take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
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Nursing Process/Diagnoses Practice Test (NCLEX style) 15 multiple choice
Nursing Process/diagnoses Practice Test (Nclex
Style) 15 Multiple Choice
by SonyaStephensKuhn, Aug 2014
Subjects: nursing
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Answer: B
Rationale- The nurse identifies
The nurse in charge human responses to actual or
identifies a patient's potential health problems
responses to actual or during the nursing diagnoses
potential health problems step of the nursing process.
during which step of the During the assessment step,
nursing process? the nurse collects data. During
the planning step, the nurse
A. Assessing develops strategies to resolve
B. Diagnosing or decrease the patient's
C. Planning problem. During evaluation,
D. Evaluating the nurse determines the
effectiveness of the plan of
care.
Answer: D
A female patient is
diagnosed with deep-vein Rationale: This answer takes
thrombosis. Which nursing highest priority because
diagnosis should receive the venous inflammation and clot
highest priority at this time? formation impede blood flow
in a patient with deep-vein
A. Impaired gas exchange thrombosis.
related to increased blood
flow Option A is incorrect because
B. Fluid volume excess impaired gas exchange is
related to peripheral related to decreased, not
vascular disease increased, blood flow. Option B
C. Risk for injury related to is inappropriate because no
edema evidence suggests that this
D. Altered peripheral tissue patient has a fluid volume
perfusion related to venous excess. Option C may be
congestion warranted but is secondary to
altered tissue perfusion
Answer: D
A nurse is revising a client's
care plan. During which Rationale: During the
step of the nursing process evaluation step of the nursing
does such a revision take process the nurse determines
place? whether the goals established
have been achieved, and
A. Assessment evaluates the success of the
B. Planning plan. Answer A involves data
C. Implementation collection. Answer B involves
D. Evaluation setting priorities, and Answer C
is the actual intervention.
Which intervention should Answer: D
the nurse in charge try first
for a client that exhibits Rationale: You should begin
signs of sleep disturbance? with the simplest
A. Administer sleeping
medication before bedtime
interventions. Answer A is
B. Ask the client each
incorrect because medications
morning to describe the
should be avoided whenever
quantity of sleep the night
possible. Answer B would be a
before
thorough sleep assessment,
C. Teach the client
and should be done only after
relaxation techniques, such
common sense interventions
as guided imagery and
fail. Answer C would be
progressive muscle
appropriate only after common
relaxation
sense interventions fail.
D. Provide the client normal
sleep aids, such as pillows,
back rubs, and snacks
A nurse is assigned to care Answer: C
for a postoperative male
client who has diabetes Rationale- Making appropriate
mellitus. During the referrals is a valid part of
assessment interview, the planning the client's care. The
client reports that he's nurse normally does not
impotent and says he's provide sex counseling. While
concerned about the effect providing time for privacy and
on his marriage. In planning providing support for the
this client's care, the most spouse is important, it is not as
appropriate intervention important as referring the
would be to: client to a sex
counselor/appropriate
A. Encourage the client to professional.
ask questions about
personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex
counselor or other
appropriate professional
D. Provide support for the
spouse
Using Maslow's hierarchy of
Answer- A
needs, a nurse assigns the
highest priority to which
Rationale - According to
client need?
Maslow, elimination is a first-
level or physiological need.
A. Elimination
Security and safety are second-
B. Security
level needs, and belonging is a
C. Safety
third-level need.
D. Belonging
A female client who
received general anesthesia
returns from surgery.
Postoperatively, which
nursing diagnosis takes Answer: D
highest priority for this
client? Rationale- Risk for aspiration
takes priority because general
A. Acute pain R/T surgery anesthesia may impair gag and
B. Deficient fluid volume swallow reflexes. The other
R/T blood and fluid loss options, although important,
from surgery are secondary to this.
C. Impaired physical
mobility R/T surgery
D. Risk for aspiration R/T
anesthesia
A male client is admitted to Answer: A
the hospital with blunt
chest trauma after a motor Rationale- The first priority is
vehicle accident. The first to evaluate airway patency.
nursing priority for this Pain management and
client would be to: splinting are important for
client comfort, but come after
A. Assess the client's airway
an airway assessment.
B. Provide pain relief
Coughing and deep breathing
C. Encourage deep
may be contraindicated if the
breathing and coughing
client has internal bleeding and
D. Splint the chest wall with
other injuries.
a pillow
When two nursing
diagnoses appear closely
related, what should the
nurse do first to determine Answer: D
which diagnosis most
accurately reflects the Rationale- The first thing a
needs of a patient? nurse should do to
differentiate is to compare the
A. Reassess the patient data collected to the major and
B. Examine the related to minor defining characteristics
factors of each of the nursing
C. Analyze the secondary to diagnoses being considered.
factors
D. Review the defining
characteristics
The nurse performs an Answer: D
assessment of a newly
admitted patient. The nurse Rationale- This is the primary
understands that this purpose of a nursing admission
admission assessment is assessment.
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
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