1. Rationale: Asking about the weather initiates the 4.

Rationale: Validation is the process of

social or introductory phase of the interview and confirming that data are actual and factual. Data
allows the nurse to begin an assessment of the that can be measured can be accepted as factual,
client's mental status. The goal is to develop as in options 1, 3 and 4. The nurse should assess
rapport with the client at the beginning of the the client's toe to validate the statement.
interview. In the body the client responds to the The nurse needs to validate which of the
nurse's questions. During the closing the nurse following statements pertaining to an assigned
or the client terminates the interview. During client?
which part of the client interview would it be A. The client has a hard, raised, red lesion on his
best for the nurse to ask, "What's the weather right hand.
forecast for today?" B. A weight of 185 lbs. is recorded in the chart
A. Introduction C. The client reported an infected toe
B. Body D. The client's blood pressure is 124/70. It was
C. Closing 118/68 yesterday.
D. Orientation C. The client reported an infected tow
A. Introduction
5. Rationale: Subjective data includes the client's
2. Rationale: This is an open-ended question that sensations, feelings, and perception of health
will elicit subjective data. The data collected will status. Subjective data can only be verified by
reflect the client's current health status and the affected person. Options 1, 2, and 3 represent
human response(s) and should generate specific objective data that can be detected by the nurse
information that can be used to identify actual or measured against an accepted norm. Which of
and/or potential health problems. Options 2 and the following items of subjective client data
3 are more likely to elicit general, nonspecific would be documented in the medical record by
information. Option 4 may result in a brief, one- the nurse?
word response or nonverbal gesture indicating A. Client's face is pale
the site of the client's pain. A better approach to B. Cervical lymph nodes are palpable
collect specific information might be, "Describe C. Nursing assistant reports client refused lunch
any pain you are having." The nurse is most D. Client feel nauseated
likely to collect timely, specific information by D. Client feel nauseated
asking which of the following questions?
A. "Would you describe what you are feeling?" 6. Rationale: The nursing process is characterized
B. "How are you today?" by unique properties that enable it to respond to
C. "What would you like to talk about?" the changing health status of the client. Options
D. "Where does it hurt?" 1, 2, and 3 are appropriate nursing care
A. "Would you describe what you are feeling?" measures, but do not demonstrate the dynamic
nature of the nursing process. A nurse explains
3. Rationale: A leading question directs the client's to a student that the nursing process is a dynamic
answer. The phrasing of the question indicates process. Which of the following actions by the
an expected answer. The client may be nurse best demonstrates this concept during the
influenced by the nurse's expectations and may work shift?
give inaccurate responses. This process can A. Nurse and client agree upon health care goals
result in an error in diagnostic reasoning. for the client
The nurse should avoid asking the client which B. Nurse reviews the client's history on the
of the following leading questions during a medical record
client interview? C. Nurse explains to the client the purpose of
A. "What medication do you take at home?" each administered medication
B. "You are really excited about the plastic D. Nurse rapidly reset priorities for client care
surgery, aren't you?" based on a change in the client's condition
C. "Were you aware I've has this same type of D. Nurse rapidly reset priorities for client care
surgery?" based on a change in the client's condition
D. "What would you like to talk about?"
B. "You are really excited about the plastic 7. Rationale: Assessment involves the systematic
surgery” collection of data about an individual upon
which all subsequent phases of the nursing
process are built. In response to a client's
 complaint, a nurse assesses a specific body life process, event, or stressor. These are
system to obtain data that will help the nurse categorized as nursing diagnoses. The incorrect
make a nursing diagnosis and plan the client's options are cues the nurse would use to
care. The other options reflect interventions, formulate the nursing diagnostic statement.
which are not timely unless there is first a Which of the following descriptors is most
complete assessment. The client reports nausea appropriate to use when stating the "problem"
and constipation. Which of the following would part of a nursing diagnosis?
be the priority nursing action? A. Grimacing
A. Collect a stool sample B. Anxiety
B. Complete an abnormal assessment C. Oxygenation saturation 93%
C. Administer an anti-nausea medication D. Output 500 mL in 8 hours
D. Notify the physician B. Anxiety
B. Complete an Abdominal assessment
11. Rationale: An outcome statement must describe
8. Rationale: To collect data accurately, the client the observable client behavior that should occur
must actively participate. Incomplete data can in response to the nursing interventions. It
lead to inappropriate nursing diagnosis and consists of a subject, action verb, conditions
planning. The other options are not relevant to under which the behavior is to be performed,
the question as presented. The nurse suspects and the level at which the client will perform the
that a client is withholding health-related desired behavior. Each of the incorrect options
information out of fear of discovery and possible lacks one of these required elements. Option 1 is
legal problems. The nurse formulates nursing not measurable. Option 3 is a nursing goal rather
diagnoses for the client carefully, being than a client goal. Option 4 does not include the
concerned about a diagnostic error resulting level at which the behavior should be performed.
from which of the following? Which desired outcome written by the nurse is
A. Incomplete data correctly written and measurable?
B. Generalize from experience A. Client will have a normal bowel pattern by
C. Identifying with the client April 2
D. Lack of clinical experience B. The client will lose 4 lbs. within next 2 weeks
A. Incomplete data C. The nurse will provide skin care at least 3
times each day
9. Rationale: A nursing diagnosis is a clinical D. The client will breathe better after resting for
judgment about a response to an actual or 10 minutes
potential health problem. This client is B. The client will lose 4 lbs. within next 2 weeks
manifesting symptoms of both hopelessness and
powerlessness. Although the client does report 12. Rationale: Long-term goals describe changes in
symptoms compatible with fatigue, there is no client behavior expected over a time frame
direct data is given that indicates the client has greater than one week. They are usually
interrupted sleep patterns (option 3), disturbed designed to restore normal functioning in a
self esteem (option 4), or self care deficit (option problem area and are helpful to other healthcare
5). The nurse notes that the client often sighs workers who care for the client, often in a
and says in a monotone voice, "I'm never going variety of settings. The rehabilitation nurse
to get over this." When encouraged to participate wishes to make the following entry into a client's
in care, the client says, "I don't have the energy." plan of care: "Client will reestablish a pattern of
The nurse believes these cues are suggestive of daily bowel movements without straining within
which nursing diagnoses? Select all that apply. two months." The nurse would write this
A. Hopelessness statement under which section of the plan of
B. Powerlessness care?
C. Interrupted sleep pattern A. Nursing diagnosis/problem list
D. Disturbed self esteem B. Nursing orders
E. Self care deficit C. Short-term goals
A. Hopelessness D. Long-term goals
B. Powerlessness D. Long-term goals

10. Rationale: The problem part of a nursing 13. Rationale: Outcome goals should be SMART,
diagnosis should state the client's response to a i.e., Specific, Measurable, Appropriate,
 Realistic, and Timely. Option 1 is the only D. Observe client's skin color and take another
outcome that has a specific behavior (walks set of vital signs
daily), with measurable performance criteria (2
miles), and a time estimate for goal attainment 16. Rationale: Interpersonal skills are the sum of the
(by March 19). activities the nurse uses when communicating
Which of these is a correctly stated outcome with others. Technical/psychomotor skills are
goal written by the nurse? "hands-on" skills, which are often procedures
A. The client will walk 2 miles daily by March and are evaluated by return demonstration.
19 Cognitive skills are the intellectual skills of
B. The client will understand how to give insulin analysis and problem-solving and are evaluated
by discharge by [Link] instructing the client on crutch
C. The client will regain their former state of walking technique, the nurse should evaluate the
health by April 1 client's understanding by using which of the
D. The client achieve desired mobility by May 7 following methods?
A. The client will walk 2 miles daily by March A. Return demonstration
19 B. Explanation
C. Achievement of 90 on written test
14. Rationale: The human response/label is what D. Have client explain produce to the family
needs to change (Risk for impaired skin A. Return demonstration
integrity). The label suggests the outcomes. In
this case, "skin will remain intact" is the desired 17. Rationale: The implementation phase of the
outcome for a client at risk for impaired skin nursing process involves carrying out or
integrity. Option 1 addresses immobility. Option delegating the nursing interventions and
3 addresses pain. Option 4 is an intervention. recording nursing activities and client responses
The nursing diagnosis is Risk for impaired skin in the medical records. Option 1 represents
integrity related to immobility and pressure diagnosing. Option 3 represents planning.
secondary to pain and presence of a cast. Which Option 4 represents evaluation. The nurse would
of the following desired outcomes should the do which of the following during the
nurse include in the care plan? implementation phase of the nursing process
A. Client will be able to turn self by day 3 when working with a hospitalized adult?
B. Skin will remain intact and without redness A. Formulate a nursing diagnosis of impaired
during hospital stay gas exchange
C. Client will state pain relieved within 30 B. Record in the medical record the distance a
minutes after medication client ambulate in the hall
D. Pressure will be prevented by repositioning C. Write individualized nursing orders in the
client every 2 hours care plan
B. Skin will remain intact and without redness D. Compare client responses to the desired
during hospital stay outcomes for pain relief
B. Record in the medical record the distance a
15. Rationale: Assessment is ongoing throughout the client ambulate in the hall
nurse-client relationship. During re-assessment,
the nurse collects additional data to help 18. Rationale: Subjective data includes thoughts,
evaluate the status of problems or identify new beliefs, feelings, perceptions, and sensations that
problems. Options 1, 2, and 3 are interventions. are apparent only to the person affected and
While assisting a client from bed to chair, the cannot be measured, seen, or felt by the nurse.
nurse observes that the client looks pale and is This information should be documented using
beginning to perspire heavily. The nurse would the client's exact words in quotes. The other
then do which of the following activities as a options indicate that the nurse has drawn the
reassessment? conclusion that the client no longer wishes to
A. Help client into the chair but more quickly live. From the data provided, the cues do not
B. Document client's vital signs taken just prior support this assumption. A more complete
to moving the client assessment should be conducted to determine if
C. Help client back to bed immediately the client is suicidal. A client on the nursing unit
D. Observe client's skin color and take another is terminally ill but remains alert and oriented.
set of vital signs Three days after admission, the nurse observes
signs of depression. The client states, "I'm tired
 of being sick. I wish I could end it all." What is This information should be documented using
the most accurate and informative way to record the client's exact words in quotes. The other
this data in a nursing progress note? options indicate that the nurse has drawn the
A. Client appears to be depressed, possibly conclusion that the client no longer wishes to
suicidal live. From the data provided, the cues do not
B. Client reports being tired of being ill and support this assumption. A more complete
wants to die assessment should be conducted to determine if
C. Client does not want to live any longer and is the client is suicidal. A client on the nursing unit
tired of being ill is terminally ill but remains alert and oriented.
D. Client states, "I'm tired of being sick. I wish I Three days after admission, the nurse observes
could end it all." signs of depression. The client states, "I'm tired
D. Client states, "I'm tired of being sick. I wish I of being sick. I wish I could end it all." What is
could end it all." the most accurate and informative way to record
this data in a nursing progress note?
19. Rationale: Interpersonal skills are the sum of the A. Client appears to be depressed, possibly
activities the nurse uses when communicating suicidal
with others. Technical/psychomotor skills are B. Client reports being tired of being ill and
"hands-on" skills, which are often procedures wants to die
and are evaluated by return demonstration. C. Client does not want to live any longer and is
Cognitive skills are the intellectual skills of tired of being ill
analysis and problem-solving and are evaluated D. Client states, "I'm tired of being sick. I wish I
by tests. After instructing the client on crutch could end it all."
walking technique, the nurse should evaluate the D. Client states, "I'm tired of being sick. I wish I
client's understanding by using which of the could end it all."
following methods?
A. Return demonstration 22. Rationale: To discontinue a diagnosis once it has
B. Explanation been resolved, cross it off with a single line or
C. Achievement of 90 on written test highlight it, then write initials and date. Some
D. Have client explain produce to the family agency forms may require the nurse to put date
A. Return demonstration and initials in a "Date Resolved" column. Using
Liquid PaperTM is not a legal way to amend
20. Rationale: The implementation phase of the client records. Outcome goals that have been
nursing process involves carrying out or met and nursing diagnoses that have been
delegating the nursing interventions and resolved should be documented on the care plan.
recording nursing activities and client responses A progress note should also be written, but a
in the medical records. Option 1 represents single note may not be read by all health team
diagnosing. Option 3 represents planning. members. he nurse evaluates the client's progress
Option 4 represents evaluation. The nurse would and determines that one of the nursing diagnoses
do which of the following during the on the client's care plan has been resolved. How
implementation phase of the nursing process should the nurse document this so that it is best
when working with a hospitalized adult? communicated to the healthcare team?
A. Formulate a nursing diagnosis of impaired A. Use Liquid PaperTM to "white out" the
gas exchange resolve diagnosis on the care plan
B. Record in the medical record the distance a B. Recopy the care plan without the resolve
client ambulate in the hall diagnosis
C. Write individualized nursing orders in the C. Write a nursing process not indicating that the
care plan outcome goals have been achieved
D. Compare client responses to the desired D. Draw a single line through the diagnosis on
outcomes for pain relief the care plan and write the nurse's initials and
B. Record in the medical record the distance a date
client ambulate in the hall D. Draw a single line through the diagnosis on
the care plan and write the nurse's initials and
21. Rationale: Subjective data includes thoughts, date
beliefs, feelings, perceptions, and sensations that
are apparent only to the person affected and 23. Rationale: Terminal evaluation is done to
cannot be measured, seen, or felt by the nurse. determine the client's condition at the time of
 discharge. This evaluation is best reflected in closed-ended question generally requires only a
option 2 because it focuses on which goals were "yes" or "no" or short factual answer. Open-
achieved and which were not. Ongoing ended questions encourage clients to elaborate
evaluation is done while or immediately after on their thoughts and feelings. Neutral questions
implementing a nursing intervention. do not influence the client's answer. The nurse
Intermittent evaluation is performed at specified overhears an unlicensed assistive person (UAP)
intervals, such as twice a week. Items related to who has just been accepted to nursing school say
care post-discharge (options 2, 3, and 4) should to a client, "You must be so pleased with your
be done on admission to the LTC facility. The progress." The nurse later explains to the UAP
client is being discharged to a long-term care that this is an example of what type of question?
(LTC) facility. The nurse is preparing a progress A. Close-ended question
note to communicate to the LTC staff the client's B. Open-ended question
outcome goals that were met and those that were C. Leading question
not. To do this effectively, the nurse should: D. Neutral question
A. Formulate post-discharge nursing diagnoses C. Leading question
B. Draw conclusion about resolution of current
client problems 26. Rationale: The diagnosing phase of the nursing
C. Assess the client for baseline data to be used process involves data analysis, which leads to
at the LTC facility identification of problems, risks, and strengths
D. Plan the care that is needed in the LTC and the development of nursing diagnoses.
facility Collecting and organizing client data is done in
B. Draw conclusion about resolution of current the assessment phase of the nursing process.
client problems Goal setting occurs during the planning phase.

24. Rationale: To collect data accurately, the client 27. The nurse would do which of the following
must participate. Attending to the client's activities during the diagnosing phase of the
immediate personal needs before expecting the nursing process? Select all that apply.
client to focus on the interview will maximize A. Collect and organize client information
the accuracy of the data collected. Data should B. Analyze data
be collected shortly after admission. The best C. Identify problems, risk, and client strengths
source of data is the client. The management of D. Develop nursing diagnoses
the client's anxiety is the responsibility of the E. Develop client goals
nurse conducting the interview and initiating the B. Analyze data
relationship. A client who complains of nausea C. Identify problems, risk, and client strengths
and seems anxious is admitted to the nursing D. Develop nursing diagnoses
unit. The nurse should take which of the
following actions regarding completion of the 28. Rationale: The description indicates a healthy
admission interview? pattern of nutrition for the client. A wellness
A. Help the client to get settled and do the diagnosis might be stated as: "Potential for
interview the next morning when the client is enhanced nutrition." An actual health problem is
rested a client problem that is currently present. The
B. Do the interview immediately, directing the nurse should also do a diet assessment to
majority of the questions to the client's spouse determine the quality of the food eaten during
C. Do the interview as soon as some meals. These actions by the nurse are within the
uninterrupted time is available in order to scope of independent nursing practice and are
address the client's concerns not collaborative in nature. The functional health
D. Ask the charge nurse to interview the client pattern assessment data states: "Eats three meals
while the admitting nurse calls the doctor for a day and is of normal weight for height." The
anti-nausea and anti-anxiety medication nurse should draw which of the following
C. Do the interview as soon as some conclusions about this data? Select all that
uninterrupted time is available in order to apply.
address the client's concerns A. Client has an actual health problem
B. Client has a wellness diagnosis
25. Rationale: A leading question is asked in a way C. Collaborative health problem needs to be
that suggests the type of answer that is expected. written
This can result in inaccurate data collection. A D. Possible nursing diagnosis exists
 E. Specific questions about the diet should be active involvement in the healthcare process for
asked next the client. In this case collaboration with other
B. Client has a wellness diagnosis nursing staff will ensure the successful
E. Specific questions about the diet should be implementation of the planned intervention.
asked next There is no real need for collaboration with
hospital administration or the security
29. Rationale: The etiology or related factors of a department in this situation although the nurse
nursing diagnostic statement define one or more should be aware of her responsibility to
probable causes of the problem and allow the collaborate at those levels when the situation
nurse to individualize the client's care. In this demands it. The nurse decides it would be
case, the fracture is the cause of the client's beneficial to the client to allow the client's infant
feeding problem. For the nursing diagnostic granddaughter to visit before the client's
statement, Self-care deficit: feeding related to scheduled heart transplant. Before implementing
bilateral fractured wrists in casts, what is the this intervention the nurse should collaborate
major related factor or risk factor identified by with which of the following? Select all that
the nurse? apply.
A. Discomfort A. Client and Family
B. Deficit B. Other nursing staff on the unit
C. Feeding C. Security department
D. Fractured wrists D. Hospital administration
D. Fractured Wrists E. This is not a collaborative intervention so no
collaboration will be needed prior to
30. Rationale: An inference is the nurse's judgment implementation
or interpretation of cues such as judging a blood A. Client and Family
pressure to be lower than normal. A cue is any B. Other nursing staff on the unit
piece of data information that influences a
decision. Options 2, 3, and 4 are cues that could 33. Rationale: The nurse is responsible for
lead to inferences. The nurse would make which coordinating the plan of care with other
of the following inferences after performing the disciplines to ensure the client's safety. This
appropriate client assessment? action represents the implementation phase of
A. Client is hypotensive the nursing process. Data gathering occurs
B. Respiratory rate of 20 breaths per minute during assessment. Goal setting occurs during
C. Oxygen saturation of 95% planning. Determining attainment of client goals
D. Client relays anxiety about blood work occurs as part of evaluation. The nurse informs
A. Client is hypotensive the physical therapy department that the client is
too weak to use a walker and needs to be
31. Rationale: Outcome statements must be written transported by wheelchair. Which step of the
in behavioral terms and identify specific, nursing process is the nurse engaged in at this
measurable client behaviors. They are stated in time?
terms of the client with an action verb that, A. Assessment
under identified conditions, will achieve the B. Planning
desired behavior. They should also be realistic C. Implementation
and achievable. The nurse would write which of D. Evaluation
the following outcome statements for a client C. Implementation
starting an exercise program?
A. Client will walk quickly three times a day 34. Rationale: The goal has not been met because
B. Client will be able to walk a mile the client states only two out of three signs of
C. Client will have no alteration in breathing impaired circulation. By comparing the data
during the walk with the expected outcomes, the nurse judges
D. Client will progress to walking a 20-minute that while there has been progress toward the
mile in one month goal, it has not been completely met. The care
D. Client will progress to walking a 20-minute plan may need to be revised or more effective
mile in one month teaching strategies may need to be implemented
to achieve the goal. A desired outcome for a
client immobilized in a long leg cast reads;
32. Rationale: Collaboration with the client and
Client will state three signs of impaired
family will encourage a sense of autonomy and
circulation prior to discharge. When the nurse
evaluates the client's progress, the client is able
to state that numbness and tingling are signs of
impaired circulation. What would be an
appropriate evaluation statement for the nurse to
write?
A. Client understands the signs of impaired
circulation
B. Goal met: Client cited numbness and tingling
as sign of impaired circulation
C. Goal not met: Client able to name only two
signs of impaired circulation
D. Goal not met: Client unable to describe signs
of impaired circulation
C. Goal not met: Client able to name only two
signs of impaired circulation