"NCLEX" - Type Nursing Process pt 1

Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need? A. Elimination B. Security C. Safety D. Belonging

(Answer: ) A (Rationale - According to Maslow, elimination is a first-level or physiological need. Security and safety are second-level needs, and belonging is a third-level need.)

Independent nursing interventions commonly used for patients with pressure ulcers include: A. changing the patient's position regularly to minimize pressure B. Applying a drying agent such as an antacid to decrease moisture at the ulcer site C. Debriding the ulcer to remove necrotic tissue, which can impede healing D. Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated

(Answer: ) A (Rationale- Independent nursing interventions for a patient with pressure ulcers commonly include changing positions. B, C, & D all require a physician's order. Additionally, a drying agent, answer B would be contraindicated because the wound needs moisture to heal.)

A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Risk for aspiration R/T anesthesia B. Deficient fluid volume R/T blood and fluid loss from surgery C. Impaired physical mobility R/T surgery D. Acute pain R/T surgery

(Answer: ) A (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

(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.)

Which of the following is an appropriate etiology for a nursing diagnosis? A) Incisional pain B) Poor hygienic practices C) Needs bedpan frequently D) Inadequate prescription of medication by the physician

(Answer: ) A (Rationale- A. Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition that identifies the cause of a client's response to a health problem that a nurse can treat or manage. B. "Poor hygiene practices" would not be an appropriate etiology for a nursing diagnosis because it insinuates a nurse's prejudicial judgment. C. "Needs bedpan frequently" is not an appropriate etiology because it identifies a nursing intervention, not an etiology. D. "Inadequate prescription of medication by the physician" is not an appropriate etiology because it identifies the nurse's problem, not the client's problem. The nursing diagnosis should center attention on client needs.)

Which of the following is an appropriately written nursing diagnosis? A) Pain related to insufficient use of medication B) Pain related to difficulty ambulating C) Anxiety related to cardiac monitor D) Bedpan required frequently as a result of altered elimination pattern

(Answer: ) A (Rationale- A. This is an example of an appropriately written nursing diagnosis. It consists of a diagnostic label and the associated etiology. Nursing interventions can be directed at treating or managing the behavior of insufficient medication use. note: for purposes of this example there are no signs and symptoms listed. In an actual diagnosis the S/S would need to be listed as well. B. This nursing diagnosis is not written correctly. What could be a defining characteristic S/S is used as an etiology. This nursing diagnosis could be rewritten more appropriately as Impaired mobility related to pain as evidenced by difficulty ambulating. C. This nursing diagnosis is written incorrectly because it identifies the equipment rather than the client's response to the equipment. It would be appropriate to state deficient knowledge regarding the need for cardiac monitoring. D. This nursing diagnosis is written incorrectly because it identifies a nursing intervention, not the client's problem. It could be reworded, Diarrhea related to food intolerance for example.)

The nurse notes a narcotic is to be administered per epidural cath. The nurse, however, does not know how to perform this procedure. Which aspects of the implementation process should be followed? A) Seek assistance B) Reassess the client C) Use interpersonal skills D) Critical decision making

(Answer: ) A (Rationale- A: If a nurse does not know how to perform a procedure, he or she should seek assistance. Information about the procedure is obtained from the literature and the agency's procedure book. All equipment necessary for the procedure is collected. Finally, another nurse who has completed the procedure correctly and safely provides assistance and guidance. B. Reassessing the client is a partial assessment that may focus on one dimension of the client or on one system. It provides a way to determine whether the proposed nursing action is still appropriate for the client's level of wellness. C. Interpersonal skills are used to develop a trusting relationship, express a level of caring, and communicate clearly with the client, family, and health care team. D. Critical decision making is used when the nurse implements the care plan by using the knowledge bases necessary for care planning and for then completing the planned interventions most effectively. In this case, the nurse lacks the necessary knowledge and experience and should seek assistance.)

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. Identify important data C. Establish a therapeutic relationship D. Ensure that the patient's skin is intact

(Answer: ) B (Rationale- This is the primary purpose of a nursing admission assessment.)

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.)

The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse she wants to have her hair shampooed. How would the nurse prioritize this client need? A) Immediate priority B) Low priority C) Intermediate priority D) High priority

(Answer: ) B (Rationale- B. The client's request would be of low priority because it is not directly related to a specific illness or prognosis. D. The client's request is not a high priority. It is not a life-threatening situation. C. The client's request is not an intermediate priority. An intermediate priority is one that involves the nonemergency, non-life threatening needs of the client. A. The client's request is not an immediate priority. It is not a life-threatening situation.)

A nurse is assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to: A. Encourage the client to 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

(Answer: ) C (Rationale- Making appropriate referrals is a valid part of planning the client's care. The nurse normally does not provide sex counseling. While providing time for privacy and providing support for the spouse is important, it is not as important as referring the client to a sex counselor/appropriate professional)

While the nurse is providing a patient personal hygiene, she observes that his skin is excessively dry. During the procedure, he tells her that he is very thirsty. An appropriate nursing diagnosis would be: A. Potential for impaired skin integrity R/T altered gland function B. Potential for impaired skin integrity R/T dehydration C. Impaired skin integrity R/T dehydration D. Impaired skin integrity R/T altered circulation

(Answer: ) C (Rationale- The appropriate diagnosis for a patient with excessively dry skin is impaired skin integrity - actual not potential. R/T dehydration is appropriate because the patient complained of thirst.)

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. Review the defining characteristics, D. Analyze the secondary to factors

(Answer: ) C (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.)

Accountability is a critical aspect of nursing care. An example of accountability is demonstrated by: A) Selecting the medication schedule for the client B) Implementing discharge teaching plans that meet individual needs C) Evaluating the client's outcomes after implementation of care D) Promoting participation of all staff members in unit meetings

(Answer: ) C (Rationale- C: Accountability refers to individuals being answerable for their actions. It involves follow-up and a reflective analysis of one's decisions to evaluate their effectiveness. A. Selecting the medication schedule for the client is an example of taking responsibility. B. Implementing discharge-teaching plans that meet individual needs is an example of autonomy. D. Promoting participation of all staff members in unit meetings is an example of promoting authority.)

Of the following statements, which one is an example of an appropriately written nursing diagnosis? A) Acute pain related to left mastectomy B) Impaired gas exchange related to altered blood gases C) Deficient knowledge related to need for cardiac catheterization D) Need for high protein diet related to alteration in nutrition

(Answer: ) C (Rationale- C: This nursing diagnosis is written correctly. It defines a problem and its possible cause; in this case, the problem is the client's response to a diagnostic test. a. A medical diagnosis should not be recorded as an etiology because nursing interventions cannot change the medical diagnosis. It would be appropriate to state Acute pain related to impaired skin integrity secondary to mastectomy incision. b. This nursing diagnosis is written incorrectly because it uses supportive data of the problem as an etiology. d. This nursing diagnosis does not identify the problem and etiology. It identifies the client's goal rather than the problem. It could be reworded as Imbalanced nutrition: less than body requirements related to inadequate protein intake.)

During an interview, the nurse needs to obtain specific information about the signs and symptoms of a health problem. To obtain these data most efficiently, the nurse should use: A) Active listening B) Open-ended questions C) Closed-ended questions D) Seeking clarification

(Answer: ) C (Rationale- C: Using closed-ended questions helps the nurse to acquire specific information about health problems such as symptoms, precipitating factors, or relief measures in an efficient manner. A. Active listening occurs when the nurse uses techniques such as "all right," "go on," or "uh-huh," to indicate that the nurse has heard what the client said and to encourage the client to elaborate further. B. Using open-ended questions prompts the client to describe a situation in more than one or two words. Because it allows the client the opportunity to tell his or her story and reveal what is important, it is not the most efficient method of obtaining specific information regarding a client's signs and symptoms of a health problem. D. In seeking clarification, the nurse attempts to make the broad meaning of the message more understandable. The nurse can restate or repeat the client's message.)

Nursing interventions should be documented according to specific criteria so they are clearly understood by other members of the nursing team. The intervention statement "Nurse will apply warm, wet soaks to the client's leg while the client is awake" lacks which of the following components? A) Method B) Quantity C) Frequency D) Qualifications of the person who will perform the task

(Answer: ) C (Rationale- The intervention statement does not include how frequently the warm soaks should be applied. A. The method is applying warm wet soaks to the patient's leg while the patient is awake. B. The quantity is warm wet soaks. D. The qualification of the person who will perform the action is the designation of "the nurse.")

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

(Answer: ) D (Rationale- A nursing diagnosis is a statement about a patient's actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never part of the nursing diagnosis.)

Independent nursing interventions commonly used for immobilized patients include all of the following except: A. Active or passive ROM exercises, body repositioning, and ADLs as tolerated B. Deep-breathing and coughing exercises with change of position every 2 hours C. Diaphragmatic and abdominal breathing exercises D. Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy

(Answer: ) D (Rationale- A, B, & C are incorrect. These are not independent nursing interventions because they require a physician's order.)

The most important nursing intervention to correct skin dryness is: A. avoid bathing until the condition is remedied and notify physician B. ask physician to refer the patient to a dermatologist C. Consult the dietitian about increasing fat intake, and take necessary measures to prevent infection D. encourage the patient to increase fluid intake, use nonirritating soap, and apply lotion to involved areas

(Answer: ) D (Rationale- Preventative measures, such as these, will prevent the skin from cracking, which would make the client more prone to infection. The other 3 answers are options, however NOT the best choice for this particular situation.)

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

(Answer: ) D (Rationale: During the evaluation step of the nursing process the nurse determines whether the goals established have been achieved, and evaluates the success of the plan. Answer A involves data collection. Answer B involves setting priorities, and Answer C is the actual intervention.)

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)

Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance? A. Administer sleeping medication before bedtime B. Ask the client each morning to describe the quantity of sleep the night before C. Teach the client relaxation techniques, such as guided imagery and progressive muscle relaxation D. Provide the client normal sleep aids, such as pillows, back rubs, and snacks

(Answer: ) D (Rationale: You should begin with the simplest interventions. Answer A is incorrect because medications should be avoided whenever possible. Answer B would be a thorough sleep assessment, and should be done only after common sense interventions fail. Answer C would be appropriate only after common sense interventions fail.)

The nurse uses a variety of skills in the application of the nursing process. An example of a cognitive nursing skill is: A) Providing a soothing bed bath B) Communicating with the client and family C) Giving an injection to the client per physician's orders D) Recognizing the potential complications of a blood transfusion

(Answer: ) D (Rationale- D: Cognitive skills involve the application of nursing knowledge. Understanding normal and abnormal physiological and psychological responses is a cognitive skill, as in recognizing the potential complications of a blood transfusion. A. Providing a soothing bed bath involves both interpersonal skills and psychomotor skills. The nurse who provides a soothing bed bath is expressing a level of caring, which is an interpersonal skill. The nurse who provides a soothing bed bath also is using a psychomotor skill in performing the bed bath correctly. B. Communicating with the client and family is an example of an interpersonal skill. C. Giving an injection to the client is a psychomotor skill.)

A nurse who specializes in care of clients with ostomies shows a client's significant other how to assist with the manipulation of ostomy equipment. The nurse demonstrating the technique to the client is using what type of nursing skill? A) Cognitive B) Interactive C) Affective D) Psychomotor

(Answer: ) D (Rationale- D: Psychomotor skills involve the integration of cognitive and motor activities, such as in providing ostomy care. A. Cognitive skills involve the application of nursing knowledge. Knowing the rationale for therapeutic interventions, understanding normal and abnormal physiological and psychological responses, and being able to identify client learning and discharge needs all require cognitive skills. B. Interpersonal skills are used when the nurse interacts with clients, their families, and other health care team members. Effective communication is an example of an interpersonal skill. C. Affective means pertaining to an emotion or mental state.)

Which of the following is classified as subjective data? A) Client appears sleepy B) No distress noted C) Abdomen soft and non-tender D) States feels anxious and tense

(Answer: ) D (Rationale- D: Subjective data are clients' perceptions about their health problems. Feeling anxious and tense is information that only the client can provide. a. Objective data are observation or measurements made by the data collector. In this example, the nurse is making the observation that the client appears sleepy. b. "No distress noted" is an example of objective data because it is an observation made by the nurse. c. "Abdomen soft and non-tender" is an example of objective data because it is an observation made by the nurse, not a client's perception.)

Nursing interventions should be documented according to specific criteria so they are clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is: A) Offer fluids to the client q 2 hours B) Observe the client's respirations C) Change the client's dressing daily D) Irrigate the nasogastric tube q 2 hours with 30 mL normal saline

(Answer: ) D (Rationale- D: This is the most appropriate intervention statement. It includes the action, frequency, quantity, and method. A. This intervention statement lacks the component of quantity. B. This intervention statement fails to indicate the frequency or method i.e., what is the nurse specifically looking for?. C. This intervention statement omits the method.)

Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. A. Admitting not knowing how to do a procedure and requesting help B. Using clever and persuasive remarks to support an opinion or position C. Accepting without question the values acquired in nursing school D. Finding a quick and logical answer, even to complex questions E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.

A. Admitting not knowing how to do a procedure and requesting help E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs. Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making clear what they do not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical thinking.

The nurse assigned to care for a postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? A. Assess the client to be sure ambulation with assistance is an appropriate care measure B. Ask the client if he or she is ready to ambulate C. Ask whether the UAP has time to assist the client D. Ask the charge nurse whether UAPs have ambulated the client during this shift

A. Assess the client to be sure ambulation with assistance is an appropriate care measure Rationale: Prior to delegating any client care responsibilities, the nurse must assess the client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4 would not constitute an assessment of the client's current status.

A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation

A. Assessment Rationale: The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data.

When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards B. Compare the reading with one taken in the opposite arm C. Determine gaps in the vital signs in the client record D. Compare the current measurement with previous ones

A. Compare this reading against defined Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older adult. The nurse compares the client's data against identified standards to determine whether this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to previous ones (option 4) will give additional client data, but the comparison alone will not determine whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current measurement.

The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source B. Subjective data from a secondary source C. Objective data from a primary source D. Objective data from a secondary source

A. Subjective data from a primary source Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source?

The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight and age. The nurse should take which of the following actions? A. Administer the medication as ordered by the prescriber B. Call the prescriber to discuss the order and the nurse's concern C. Administer the medication, but chart the nurse's concern about the dosage D. Give the client half the dosage and document accordingly

B. Call the prescriber to discuss the order and the nurse's concern Rationale: Client safety is of the utmost importance when implementing any nursing intervention. If the nurse feels that an order is unsafe or inappropriate for a client, the nurse must act as a client advocate and collaborate with the appropriate healthcare team member to determine the rationale for the order and/or modify the order as necessary. A nurse accepts accountability for his or her actions. Options 1, 3, and 4 are inappropriate and unsafe.

The nurse would place which correctly written nursing diagnostic statement into the client's care plan? A. Cancer relater to cigarette smoking B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen saturation of 91% C. Imbalance nutrition: more than body requirement related to overweight status D. Impaired physical mobility related to generalized weakness and pain

B. Impaired gas exchange related to aspiration of foreign matter as evidence by oxygen saturation of 91% Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human response) names/labels the problem. The second part (related factors) includes the factors that either contribute to or are probable etiologies of the human response. Some formats include a third part to the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms and is joined to the statement with the label as evidenced by. This type of statement is the most complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague.

The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

B. Planning Rationale: The planning step of the nursing process involves formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a client's human response, and once a plan is established, the interventions are implemented (option 3) and evaluated (option 4).

The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis

B. Reexamine the nursing orders Rationale: The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome.

When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B. Suggesting the medication can be diluted in a beverage C. Asking the nurse manager about how to approach the situation D. Notifying the physician inability to give the client this medication

B. Suggesting the medication can be diluted in a beverage Rationale: Diluting the medication in a beverage may make the medication more palatable. Using critical thinking skills, the nurse should try to problem-solve in a situation such as this before asking for the assistance of the nurse manager. Suggesting an alternative method of taking the medication (provided that there are no contraindications to diluting the medication) should improve the likelihood of the client taking the medication.

The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B. The client's urine output was 450 mL C. The client states, "I didn't see any stones in my urine." D. The client states, "I feel like I have passed a stone."

B. The client's urine output was 450 mL. Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse. The objective data is the measurement of the urine output. A client's statements and reports of symptoms are documented as subjective data, such as the data found in options 1, 3, and 4.

Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? A. Use the previous, less restrictive policy conscientiously B. Express immediate disagreement with the new policy C. Ask for the rationale behind the new policy D. Obey the policy but continue to voice disapproval of it to co-workers

C. Ask for the rationale behind the new policy Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed change and understand its purpose. Options 1, 2, and 4 represent unprofessional behavior. Option 1 also places a client's safety at risk.

Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge E. Client will be medicated every 4 hours by the nurse

C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal.

In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction B. Instruct the client to make dietary changes by reducing sodium intake C. Include the client and family when setting goals and formulating the plan of care D. Assess past compliance to medication regimens

C. Include the client and family when setting goals and formulating the plan of care Rationale: In developing a plan of care, nurses engage in a partnership with the client and family. Nurses do not plan care for clients; instead they plan care with clients and families. Assessment (option 4), goal setting (option 1), and interventions (option 2) will be most accurate and effective when carried out in partnership with the client and family. The other options represent other actions to take, but they will have less overall effectiveness if the client and family are not part of the plan.

The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein intake C. Risk for impaired skin integrity related to malnutrition D. Impaired nutrition related to current illness

C. Risk for impaired skin integrity related to malnutrition Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or less than body requirements) and is therefore incomplete. It also does not provide direction for development of goals and interventions.

Which nurse is demonstrating the assessment phase of the nursing process? A.The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals

C. The nurse who ask the client how much lunch he or she ate Rationale: Assessment involves collecting, organizing, validating, and documenting data about a client. Option 1 represents the evaluation phase. Option 2 represents the implemention phase. Option 4 represents the planning phase.

The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior B. Conditions or modifiers C. Performance criteria D. Target time

D. Target time Rationale: The outcome goal does not state the target timeframe for when the nurse should expect to see the client behavior ("transfer"). The condition or modifier is present ("with two assists"). The performance criterion is "from bed to chair."