Nursing Process- Nursing Diagnosis

Which is the correct order of steps of the nursing diagnostic process? 1. Cluster data. 2. Identify the client's needs. 3. Formulate nursing diagnoses. 4. Look for defining characteristics. 5. Assess the client's health status. 6. Interpret the meaning of the data. 7. Validate the data with other sources.

1. Assess the client's health status. 2. Validate the data with other sources. 3. Interpret the meaning of the data. 4. Cluster data. 5. Look for defining characteristics. 6. Identify the client's needs. 7. Formulate nursing diagnoses.

The nurse is planning to provide self-care health information to several clients. Which client would the nurse anticipate will be most motivated to learn? 1 A 55-year-old client who had a mastectomy and is very anxious about her body image 2 An 18-year-old client who smokes cigarettes and is in denial about the dangers of smoking 3 A 56-year-old client who had a heart attack last week and is requesting information about exercise 4 A 47-year-old client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain

A 56-year-old client who had a heart attack last week and is requesting information about exercise

Which education would the nurse provide the parent of a preschool-age child about how preschoolers view death? 1 Universal 2 Irreversible 3 A form of sleep 4 A frightening ghost

A form of sleep

Which critical thinking skill demonstrates maturity in the nurse? 1 Eagerness to acquire knowledge 2 Being tolerant of different views 3 Trust in own reasoning processes 4 Ability to reflect on own judgments

Ability to reflect on own judgments

Which disorder would the nurse classify as neurodevelopmental? 1 Anxiety 2 Bipolar disorder 3 Schizophreniform disorder 4 Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder

The nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. Which value denotes a healthy infant? 1 Less than 40% 2 More than 75% 3 Between 45% and 65% 4 Between 65% and 75%

Between 45% and 65%

Which is the cause of milk anemia in toddlers? 1 Drinking skim milk 2 Drinking fruit juice Correct3 Increased milk intake 4 Increased intake of fruits

Increased milk intake

Which conditions are risk factors that may place infants at a higher risk for developing jaundice? Select all that apply. One, some, or all responses may be correct. 1 Infection 2 African-American race 3 Prematurity 4 Breast-feeding 5 Formula feeding 6 Maternal diabetes

Infection Prematurity Breast-feeding Maternal diabetes

Which information would the nurse include when teaching parents about the basic problem in celiac disease? 1 Green stools 2 Intolerance of gluten 3 Absence of intestinal villi 4 Susceptibility to severe dehydration

Intolerance of gluten

In the playroom of a pediatric unit, the nurse sees several toddlers seated at a table trying to copy the same picture from a book. They are not talking to each other or sharing their crayons. Which would the nurse conclude about this behavioral interaction? 1 It is a typical expression of toddlers' social development. 2 This is an example of antisocial behavior found in some children. 3 It is a lack of parental role models to demonstrate acceptable behavior. 4 This is an illustration of separation anxiety typical of hospitalized toddlers.

It is a typical expression of toddlers' social development.

The nurse identifies which physiological alteration associated with pregnancy that may change the client's response to medication? 1 Decreased glomerular filtration rate 2 Longer gastrointestinal emptying time 3 Increased secretion of hydrochloric acid 4 Development of fetal-placental circulation

Longer gastrointestinal emptying time

A breast-feeding mother experiences redness and pain in the left breast, a temperature of 100.8°F (38.2°C), chills, and malaise. Which condition would the nurse suspect? 1 Mastitis 2 Engorgement 3 Blocked milk duct 4 Inadequate milk production

Mastitis

A 26-year-old G1 P0 client at 29 weeks' gestation has gained 8 lb (3.6 kg) in 2 weeks; her blood pressure has increased from 128/74 Hg to 150/90 mm Hg; and she has developed 1+ proteinuria on urine dipstick. Which condition do these signs suggest? 1 Mild preeclampsia 2 Severe preeclampsia 3 Chronic hypertension 4 Gestational hypertension

Mild preeclampsia

Which condition would the nurse document when a newborn infant is noted to have small, flat pink spots on the nape of the neck? 1 Nevi 2 Desquamation 3 Mongolian spots 4 Erythema toxicum

Nevi

Which client is at increased risk for postpartum hemorrhage? 1 One who breast-feeds in the birthing room 2 One who receives a pudendal block for the birth 3 One whose third stage lasts less than 10 minutes 4 One who gives birth to an infant weighing 9 lb 8 oz (4366 g)

One who gives birth to an infant weighing 9 lb 8 oz (4366 g)

The nurse instills an antibiotic ophthalmic ointment into a newborn's eyes. The nurse would explain to the mother that the medication prevents which condition? 1 Ophthalmia neonatorum 2 Herpetic ophthalmia 3 Retinopathy of prematurity 4 Hemorrhagic conjunctivitis

Ophthalmia neonatorum

Which problem is suggested when a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity followed by fundal tenderness and a small amount of dark-red bleeding? 1 True labor 2 Placenta previa 3 Partial abruptio placentae 4 Abdominal muscular injury

Partial abruptio placentae

Why is a multiple-gestation pregnancy considered a high risk? 1 Postpartum hemorrhage is an expected complication. 2 Perinatal mortality is two to three times more likely in multiple than in single births. 3 Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. 4 Maternal mortality is higher during the prenatal period in the setting of multiple gestation.

Perinatal mortality is two to three times more likely in multiple than in single births.

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

Planning

Which information would the nurse use to explain a positive diagnosis for human immunodeficiency virus (HIV) infection? 1 Performance of high-risk sexual behaviors 2 Evidence of extreme weight loss and high fever 3 Identification of an associated opportunistic infection 4 Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests

Positive enzyme-linked immunosorbent assay (ELISA) and Western blot tests

The nurse suggests taking a 2-year-old child to the playroom. The child responds by shaking the head vigorously from side to side, screaming, "No! Won't!" However, the child is trying to climb out of the crib at the same time. In light of these behaviors, which is the most likely conclusion by the nurse? 1 The child is trying to assert independence. 2 The child is eager to resume regular play activities. 3 The child is unsure of the difference between yes and no. 4 The child is confused as a result of increased intracranial pressure.

The child is trying to assert independence.

The nurse creates a plan of care for a client with a risk of infection. Which is the desirable expected outcome for the client? 1 All nursing functions will be completed by discharge. 2 All invasive intravenous lines will remain patent. 3 The client will remain awake, alert, and oriented at all times. 4 The client will be free of signs and symptoms of infection by discharge.

The client will be free of signs and symptoms of infection by discharge.

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first-time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1 The nurse notes nonverbal signs of discomfort. 2 The nurse observes the client's position in bed. 3 The nurse asks the client to explain the surgery. 4 The nurse asks the client to rate the severity of pain.

The nurse asks the client to explain the surgery.

Which statement is true for collaborative problems in a client? 1 They are the identification of a disease condition. 2 They include problems treated primarily by nurses. 3 They are identified by the primary health care provider. 4 They are identified by the nurse during the nursing diagnosis stage.

They are identified by the nurse during the nursing diagnosis stage.

Which is a risk factor associated with in vitro fertilization embryo transfer (IVF-ET)? 1 Embryonic human immunodeficiency virus (HIV) Correct2 Tubal pregnancy 3 Congenital anomalies 4 Hyperemesis gravidarum

Tubal pregnancy