Which action is included in the planning process when a nurse is caring for an older adult client with AIDS?
A) Identify the client's health-related problems.
B) Analyze the client's response to medicines.
C) Assess the client's overall health.
D) Identify measurable goals or outcomes. correc...
BNS (VNSG 1323) CH. 2: "NURSING PROCESS" NCLEX-
STYLE QUESTIONS || with 100% Errorless Answers.
Which action is included in the planning process when a nurse is caring for an older adult client
with AIDS?
A) Identify the client's health-related problems.
B) Analyze the client's response to medicines.
C) Assess the client's overall health.
D) Identify measurable goals or outcomes. correct answers D) Identify measurable goals or
outcomes.
In the planning process, the nurse identifies measurable goals or outcomes, prioritizes nursing
diagnoses and collaborative problems, selects appropriate interventions and documents the plan
of care. The nurse assesses the client's overall health during the assessment step of the nursing
process, not during the planning step. The nurse identifies the client's health-related problems
during diagnosis and analyzes the client's response to medicines during the evaluation process.
A nurse is caring for a client with burns. Which nursing action in the plan of care should be
performed first by the nurse?
A) Record the color and odor of discharge.
B) Assess the condition of the wound.
C) Change the dressing of the wound.
D) Take a swab stick sample for culture. correct answers B) Assess the condition of the wound.
The nursing care plan begins with assessment. The nurse should perform the initial assessment of
the wound first and then take a swab stick sample for culture. Next, the nurse changes the
dressing of the wound and finally documents the findings.
Which nursing diagnosis has the highest priority when caring for an older adult client with
Alzheimer disease?
A) Impaired physical mobility
B) Risk for injury
C) Self-care deficit
D) Impaired memory correct answers B) Risk for injury
Clients with Alzheimer disease are highly prone to injuries. Risk of injury may also be
precipitated by the altered memory. Mortality and morbidity resulting from injury is highest in
older age groups. Consequently, it is very important for the nurse to provide a safe and secure
environment. Impaired physical mobility, self-care deficit, and impaired memory are also present
but are not the highest priority.
, A nurse is assessing a client with chronic back pain and asking specific questions to obtain a
focus assessment. Which of the following are features of a focus assessment?
A) Adds depth to existing information.
B) Provides breadth for future comparisons.
C) Suggests possible problems
D) Gives a comprehensive volume of data correct answers A) Adds depth to existing
information.
A focus assessment adds depth to existing information or the initial database gathered by the
nurse. A database assessment provides breadth for future comparisons. A focus assessment does
not suggest possible problems facing the client but rather rules out or confirms the client's
problems. A focus assessment is not voluminous and comprehensive, like a database assessment,
but limited and to the point.
A nurse is educating a client about care to be taken in the treatment of nephrotic syndrome. The
client expresses that the teachings are of no use because the disease is not curable. What nursing
diagnosis should the nurse write with regard to the client's concern?
A) Risk for powerlessness
B) Disturbed body image
C) Impaired comfort
D) Ineffective coping correct answers A) Risk for powerlessness
The most appropriate nursing diagnosis for the client is the risk for powerlessness. The client
feels that the disease is not under his control and any personal efforts will not affect outcome.
Disturbed body image is not an appropriate answer because the client does not seem to be
concerned about the appearance of his or her body. Impaired comfort is also not an appropriate
nursing diagnosis for the concern shown by the client because the client does not demonstrate
any sign of discomfort. There is a possibility that the client is not coping effectively, but the
client's statement is more directly indicative of powerlessness.
A client is brought to the Emergency Department in an unconscious condition, accompanied by
his son. The client is having respiratory arrest and is put on a ventilator. What is the most
appropriate nursing diagnosis in the client?
A) Impaired spontaneous ventilation
B) Ineffective breathing pattern
C) Ineffective airway clearance
D) Impaired gas exchange correct answers A) Impaired spontaneous ventilation
Impaired spontaneous ventilation is the most appropriate nursing diagnosis for the client because
he is unable to breath as the result of respiratory failure. Ineffective breathing pattern is
appropriate when the client has difficulty breathing due to a high respiratory rate. Ineffective
airway clearance is an inaccurate diagnosis here because the airways are clear and not blocked
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