Exam (elaborations)
"NCLEX" - Type Nursing Process - Questions/Answers
"NCLEX" - Type Nursing Process - Questions/Answers
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"NCLEX" - Type Nursing Process - Questions/AnswersThe 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 Correct Ans - (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.)
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
Correct Ans - (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)
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 Correct Ans - (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.)
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 Correct Ans - (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.)
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 Correct Ans - (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)
,Using Maslow's hierarchy of needs, a nurse assigns the highest priority to
which client need?
A. Elimination
B. Security
C. Safety
D. Belonging Correct Ans - (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.)
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 Correct Ans - (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 Correct Ans - (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.)
, 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 Correct Ans - (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.)
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 Correct Ans - (Answer: ) B
(Rationale- This is the primary purpose of a nursing admission
assessment.)
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 Correct Ans - (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.)
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