1.

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
2. 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
3. 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
4. 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
5. 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
6. Using Maslow's hierarchy of needs, a nurse assigns the highest priority to
which client need?

A. Elimination
B. Security
C. Safety
D. Belonging
7. A female client who received general anesthesia returns from surgery.
Postoperatively, which nursing diagnosis takes highest priority for this
client?

A. Acute pain R/T surgery

B. Deficient fluid volume R/T blood and fluid loss from surgery
C. Impaired physical mobility R/T surgery
D. Risk for aspiration R/T anesthesia
8. 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
9. 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. Analyze the secondary to factors
D. Review the defining characteristics
10. 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. Ensure that the patient's skin is intact
C. Establish a therapeutic relationship
D. Identify important data
11. he 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
12. Independent nursing interventions commonly used for immobilized
patients include all of the following except:

A. Active or passive ROM exercises, body repositioning, and ADLs as

tolerated
B. Deep-breathing and coughing exercises with change of position every
2 hours
C. Diaphragmatic and abdominal breathing exercises
D. Weight bearing on a tilt table, total parenteral nutrition, and vitamin
therapy\
13. Independent nursing interventions commonly used for patients with
pressure ulcers include:

A. changing the patient's position regularly to minimize pressure

B. Applying a drying agent such as an antacid to decrease moisture at
the ulcer site
C. Debriding the ulcer to remove necrotic tissue, which can impede
healing
D. Placing the patient in a whirlpool bath containing povidone-iodine
solution as tolerated
14. While the nurse is providing a patient personal hygiene, she observes
that his skin is excessively dry. During the procedure, he tells her that he
is very thirsty. An appropriate nursing diagnosis would be:

A. Potential for impaired skin integrity R/T altered gland function

 B. Potential for impaired skin integrity R/T dehydration
C. Impaired skin integrity R/T dehydration
D. Impaired skin integrity R/T altered circulation
15. The most important nursing intervention to correct skin dryness is:

A. avoid bathing until the condition is remedied and notify physician

B. ask physician to refer the patient to a dermatologist
C. Consult the dietitian about increasing fat intake, and take necessary
measures to prevent infection
D. encourage the patient to increase fluid intake, use nonirritating soap,
and apply lotion to involved areas
16. According to the holistic model, a narrow definition of holistic health includes:
A. an optimal functioning of mind, body, and spirit within the environment.
B. the absence of disease.
C. the response of the whole person to actual or potential problems.
D. the internal and external environment.
17. A medical diagnosis is used to evaluate:
A. a person's state of health.
B. the response of the whole person to actual or potential health problems.
C. a person's culture.
D. the cause of disease. An example of subjective data is:
A. decreased range of motion.
B. crepitation in the left knee joint.
C. left knee has been swollen and hot for the past 3 days.
D. arthritis.
18. Which of the following is an example of objective data?
A. Alert and oriented
B. Dizziness
C. An earache
D. A sore throat
19. An example of objective data is:
A. a complaint of left knee pain.
B. crepitation in the left knee joint.
C. left knee has been swollen and hot for the past 3 days.
D. a report of impaired mobility from left knee pain as evidenced by an inability to walk,
swelling, and pain on passive range of motion.
20. A nursing diagnosis is best described as:
A. a determination of the etiology of disease.
B. a pattern of coping.
C. an individual's perception of health.
D. a concise statement of actual or potential health concerns or level of wellness.
21. A patient admitted to the hospital with asthma has the following problems identified
based on an admission health history and physical assessment. Which problem is a first-
 level priority?
A. Ineffective self-health management
B. Risk for infection
C. Impaired gas exchange
D. Readiness for enhanced spiritual well-being

22. We know that the nurse knows the right time to do a physical assessment when
she says:

a. A.  "I will do it as soon as possible"

b. B. "I think the next shift will have to do it"

c. C. "After I give the medication"

d. D. "Maybe later, when I am done with others"

23. The most important nursing intervention to correct skin dryness is:

A. Consult the dietitian about increasing the patient’s fat intake, and take
necessary measures to prevent infection.
B. Ask the physician to refer the patient to a dermatologist, and suggest
that the patient wear home-laundered sleepwear.
C. Encourage the patient to increase his fluid intake, use non-irritating soap
when bathing the patient, and apply lotion to the involved areas.
D. Avoid bathing the patient until the condition is remedied, and notify the
physician.

24. . This is a current health concern that acts as the reason for the
health care visit.
a. Chief Complaint
b. Clinical Sign
c. Primary Diagnosis
d. Focal Point

24. This is an effective way to elicit a health history that involves a

focused conversation between the patient and the health care
provider.
25.
26. HPI ROS Patient Interview

27.  
28. Systems Review All of the answers are correct