Chapter 3 Nursing Process NCLEX Questions

Chapter 3 Nursing Process NCLEX Questions Leave the first rating Students also studied Terms in this set (16) Science MedicineNursing Save NCLEX Style Review Questions Prep...10 terms maggie_michel Preview MED/SURG Final NCLEX questions 116 terms m3clevelandPreview Ch. 9 Study Guide 40 terms ztnngvggfdPreview

Test #1:

19 terms Nic

What is "Imbalanced Nutrition: Less than the body

requirements related to loss of appetite, difficulty swallowing, and side effects of chemotherapy" an example of?

• Actual Nursing Diagnosis
• Risk Nursing Diagnosis
• Syndrome Nursing Diagnosis
• Health Promotion Nursing Diagnosis
• Actual Nursing Diagnosis

Using Maslow's hierarchy of needs arrange the following nursing diagnoses in order of highest priority to lowest priority

• Disturbed Body Image
• Sleep Deprivation
• Ineffective Relationship
• Decrease Cardiac Output
• Anxiety
• Decreased Cardiac Output
• Sleep Deprivation
• Anxiety
• Ineffective Relationship
• Disturbed Body Image

Nursing diagnoses include nursing and collaborative problems. When determining care for a client, the nurse identifies which of the following as a collaborative problem?

• Risk for Constipation related to inadequate fluid intake
• Ineffective Health Maintenance related to cognitive

impairment

• Risk of Complication for Hypogycemia
• Urinary Retention related to dysuria
• Risk of Complication for Hypoglycemia

A nurse stops to assist an adult individual involved in a motor vehicle accident. The victim was not wearing a seat belt and was thrown from the car. Of the following emergency measures, which one should the nurse perform first?

• Assess for signs of injuries
• Check the victim's breathing
• Cover the victim with a blanket
• Move the victim to the curb
• Check the victim's breathing

Nurses frequently face client situations that require critical thinking. In the following scenarios, which nurse is thinking critically?

• The nurse who is concerned about the dosage of an

ordered medication but administers it anyway.

• The nurse who makes rounds on her clients in the order

of the rooms.

• The nurse who places a seriously ill client near the

nurse's station.

• The nurse who rests an IV pump without adequate

instruction

• The nurse who places a seriously ill client near the nurse's station

As the nurse educator teaches a group pf new students about the nursing process, which of the following is the best explanation for its purpose?

• It helps to systematically plan and implement care to

meet a client's desired outcomes.

• It allows the nurse to follow steps to ensure

consistency of care among professionals.

• It provides a language that only nurses can understand

that facilitates client safety

• It represents a step by step process that anyone can

follow regardless of education

• It helps to systematically plan and implement care to meet a client's desired

outcomes There are five steps to the nursing process. When a nurse begins with setting priorities, defining expected outcomes, and determining interventions, which step is being performed?

• Assessment
• Diagnosis
• Planning
• Implementation
• Planning

The nurse has developed a nursing diagnosis with a client who has determined that she want to learn more about diet and exercise. What type of nursing diagnosis reflects the motivation by a client to increase well-being?

• Actual Nursing Diagnosis
• Risk Nursing Diagnosis
• Syndrome Diagnosis
• Health Promotion Nursing Diagnosis
• Health Promotion Nursing Diagnosis

A client has been admitted to the hospital with severe internal bleeding following a motor vehicle accident and the loss of two of his family members. According to Maslow, which of the following needs is the highest priority for the nurse when caring for a client?

• Love and belonging needs
• Self-actualization needs
• Esteem and self-esteem needs
• Physiologic needs
• Physiologic Needs

Due to demonstration of critical thinking skills the nurse manager puts a veteran nurse in charge. Critical thinking is outlined in the text as which of the following?

• structured, biased, and logical thinking
• intentional, contemplative, and out come directed

thinking

• broad, scientific, and one directional thinking
• outcome directed, broad, and biased thinking
• structured, biased, and logical thinking

The nurse arrives on the unit, gets report, and enters the client's room. What is the first step in the nursing process that the nurse will use?

• Planning
• Implementation
• Assessment
• Evaluation
• Assessment

A nurse education is teaching a group of students about the steps in concept care mapping? What is the first step in this process?

• Diagnosis
• Planning
• Assessment
• Evaluation
• Diagnosis

A nurse, implements the nursing care plan for a client but fails to document in the medical record the interventions.The functions of documentation in Alfaro-LeFreve, 2006 that come from accurate and thorough documentation include which of the following? Select all that apply.

• Creates a legal document
• Communicates care
• Supplies validation fro reimbursement
• Substantiates the care provided by ancillary staff
• Creates a legal document
• Communicates Care
• Supplies validation for reimbursement

A nurse's expected outcome for a client who is postpartum includes a goal of minimal pain of 3 on the scale of 1-10 by the end of the 7 am to 3 pm shift. The client has taken Motrin every 4 hours as ordered. At 8 am (pain level of 6 and 30 minutes later pain level of 2) as well as at 12 noon (pain level of 5 and 30 minutes later pain level of 2). Which part of the nursing process is the nurse using when analyzing the data?

• Assessment
• Evaluation
• Implementation
• Diagnosis
• Evaluation

The following is a nursing diagnostic statement: Acute

pain related to tissue trauma secondary to total knee replacement as evidenced by verbalization of pain of 8 on a scale of 1-10, restlessness, and inability to concentrate. What part of this nursing diagnosis is the name or label?

• Related to tissue trauma secondary to total knee

replacement

• As evidenced by verbalization of pain of 8 on a scale

to 1-10

• Acute Pain
• Inability to concentrate
• Acute Pain

The statement "Fatigue related to muscle wasting secondary to Parkinson's disease as evidenced by inability to maintain usual routines and verbalization of

overwhelming lack of energy." is an example of:

• Syndrome Nursing Diagnosis
• Problem-focused nursing diagnosis
• Collaborative Problem
• Health Promotion Diagnosis
• problem-focused nursing diagnosis