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

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

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
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 Nursing Process/Diagnoses Practice Test (NCLEX style) 15 multiple choice

Nursing Process/diagnoses Practice Test (Nclex

Style) 15 Multiple Choice
by SonyaStephensKuhn, Aug 2014
Subjects: nursing
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Answer: B

Rationale- The nurse identifies

The nurse in charge human responses to actual or
identifies a patient's potential health problems
responses to actual or during the nursing diagnoses
potential health problems step of the nursing process.
during which step of the During the assessment step,
nursing process? the nurse collects data. During
the planning step, the nurse
A. Assessing develops strategies to resolve
B. Diagnosing or decrease the patient's
C. Planning problem. During evaluation,
D. Evaluating 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
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
Which intervention should
the nurse in charge try first
for a client that exhibits
signs of sleep disturbance?
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
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.
Answer: D
Rationale: You should begin
with the simplest
A. Administer sleeping
medication before bedtime
interventions. Answer A is
B. Ask the client each
incorrect because medications
morning to describe the
should be avoided whenever
quantity of sleep the night
possible. Answer B would be a
before
thorough sleep assessment,
C. Teach the client
and should be done only after
relaxation techniques, such
common sense interventions
as guided imagery and
fail. Answer C would be
progressive muscle
appropriate only after common
relaxation
sense interventions fail.
D. Provide the client normal
sleep aids, such as pillows,
back rubs, and snacks

A nurse is assigned to care Answer: C

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
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.
spouse

Using Maslow's hierarchy of

Answer- A
needs, a nurse assigns the
highest priority to which
Rationale - According to
client need?
Maslow, elimination is a first-
level or physiological need.
A. Elimination 
Security and safety are second-
B. Security 
level needs, and belonging is a
C. Safety
third-level need.
D. Belonging

A female client who

received general anesthesia
returns from surgery.
Postoperatively, which
nursing diagnosis takes Answer: D
highest priority for this
client? Rationale- Risk for aspiration
takes priority because general
A. Acute pain R/T surgery  anesthesia may impair gag and
B. Deficient fluid volume swallow reflexes. The other
R/T blood and fluid loss options, although important,
from surgery  are secondary to this.
C. Impaired physical
mobility R/T surgery 
D. Risk for aspiration R/T
anesthesia

A male client is admitted to Answer: A

the hospital with blunt
chest trauma after a motor
vehicle accident. The first
nursing priority for this
client would be to:
Rationale- The first priority is
to evaluate airway patency.
Pain management and
splinting are important for
client comfort, but come after
A. Assess the client's airway
an airway assessment.
B. Provide pain relief
Coughing and deep breathing
C. Encourage deep
may be contraindicated if the
breathing and coughing 
client has internal bleeding and
D. Splint the chest wall with
other injuries.
a pillow

When two nursing

diagnoses appear closely
related, what should the
nurse do first to determine Answer: D
which diagnosis most
accurately reflects the Rationale- The first thing a
needs of a patient? nurse should do to
differentiate is to compare the
A. Reassess the patient data collected to the major and
B. Examine the related to minor defining characteristics
factors of each of the nursing
C. Analyze the secondary to diagnoses being considered.
factors
D. Review the defining
characteristics

The nurse performs an Answer: D

assessment of a newly
admitted patient. The nurse
understands that this
admission assessment is
conducted primarily to:
Rationale- This is the primary
purpose of a nursing admission
assessment.

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

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