nursing process /diagnosis questions (NCLEX styled)
A
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need? A. Elimination B. Security C. Safety D. Belonging
B
The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? A. A client's family attending a diabetic teaching session. B. Canceling physical therapy sessions on the weekend. C. Normal VS and absence of wound infection in a post-op client. D. A client demonstrating accurate medication administration following teaching.
D
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
C
The nurse writes an expected outcome statement in measurable terms. An example is: A. Client will have less pain. B. Client will be pain free. C. Client will report pain acuity less than 4 on a scale of 0-10. D. Client will take pain medication every 4 hours around the clock.
A
The nursing care plan is: A. A written guideline for implementation and evaluation. B. A documentation of client care. C. A projection of potential alterations in client behaviors D. A tool to set goals and project outcomes
D
The planning step of the nursing process includes which of the following activities? A. Assessing and diagnosing B. Evaluating goal achievement. C. Performing nursing actions and documenting them. D. Setting goals and selecting interventions.
A
To initiate an intervention the nurse must be competent in three areas, which include: A. Knowledge, function, and specific skills B. Experience, advanced education, and skills. C. Skills, finances, and leadership. D. Leadership, autonomy, and skills.
D
Well formulated, client-centered goals should: A. Meet immediate client needs. B. Include preventative health care. C. Include rehabilitation needs. D. All of the above.
D
.The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to: A. Implement the specialist's recommendations. B. Report the recommendations to the primary physician. C. Clarify the suggestions with the client and family members. D. Discuss and review advised strategies with CNS.
B
A client centered goal is a specific and measurable behavior or response that reflects a client's: A. Desire for specific health care interventions B. Highest possible level of wellness and independence in function. C. Physician's goal for the specific client. D. Response when compared to another client with a like problem.
B
A client's wound is not healing and appears to be worsening with the current treatment. The nurse first considers: A. Notifying the physician. B. Calling the wound care nurse C. Changing the wound care treatment. D. Consulting with another nurse.
D
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
D
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
A
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
C
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
D
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
CDAB
After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. A. Constipation B. Anticipated grieving C. Ineffective airway clearance D. Ineffective tissue perfusion
D
After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: A. Encourage client to implement guided imagery when pain begins. B. Determine effect of pain intensity on client function. C. Administer analgesic 30 minutes before physical therapy treatment. D. Pain intensity reported as a 3 or less during hospital stay.
B
As goals, outcomes, and interventions are developed, the nurse must: A. Be in charge of all care and planning for the client. B. Be aware of and committed to accepted standards of practice from nursing and other disciples. C. Not change the plan of care for the client. D. Be in control of all interventions for the client.
D
Collaborative interventions are therapies that require: A. Physician and nurse interventions. B. Nurse and client interventions. C. Client and Physician intervention. D. Multiple health care professionals
B
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
A
For clients to participate in goal setting, they should be: A. Alert and have some degree of independence. B. Ambulatory and mobile. C. Able to speak and write. D. Able to read and write
D
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
A
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
A
Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: A. Plan is developed for nursing care. B. Physical assessment begins C. List of priorities is determined. D. Review of the assessment is conducted with other team members.
C
Planning is a category of nursing behaviors in which: A. The nurse determines the health care needed for the client. B. The Physician determines the plan of care for the client. C. Client-centered goals and expected outcomes are established. D. The client determines the care needed.
D
Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client's: A. Physician B. Non Emergent, non-life threatening needs C. Future well-being. D. Urgency of problems
B
The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? A. A client who is ambulatory. B. A client, who has a fever, is diaphoretic and restless. C. A client scheduled for OT at 1300. D. A client who just had an appendectomy and has just received pain medication
B
The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an): A. Nursing diagnosis B. Short-term goal C. Long-term goal D. Expected outcome
D
The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of: A. Nursing interventions B. Short-term goals C. Long-term goals D. Expected outcomes
D
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
D
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
A
When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: A. Length of time the current treatment has been in place. B. The spouse's reaction to the client's dressing change. C. Client's concern about the current treatment. D. Physician's reluctance to change the current treatment plan.
B
When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: A. Apply a cold pack to the tibia. B. Elevate the leg 5 inches above the heart. C. Perform range of motion to right leg every 4 hours. D. Administer aspirin 325 mg every 4 hours as needed.
B
When establishing realistic goals, the nurse: A. Bases the goals on the nurse's personal knowledge. B. Knows the resources of the health care facility, family, and the client. C. Must have a client who is physically and emotionally stable. D. Must have the client's cooperation.
D
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
D
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
C
Which of the following nursing interventions are written correctly? Select all that apply. A. Apply continuous passive motion machine during day. B. Perform neurovascular checks. C. Elevate head of bed 30 degrees before meals. D. Change dressing once a shift
D
Which of the following statements about the nursing process is most accurate? A. The nursing process is a four-step procedure for identifying and resolving patient problems. B. Beginning in Florence Nightingale's days, nursing students learned and practiced the nursing process. C. Use of the nursing process is optional for nurses, since there are many ways to accomplish the work of nursing. D. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept.
C
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