NCP & Prioritization

Strategies
TEL: SNLEPROMETRIC
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ً‫المحاظزة االول‬

NURSING PROCESS
The steps include :

Assessment : the nurse collects data

:ٍ‫وعُذَا قسًي‬

1)Subjective date : what patient said

‫كم يا يقىنه انًريض نهًًرض يثال‬

Ex: I feel pain at my R shoulder

2)objective date:obtainted through observation, lab tests and standard assessment technique

‫او يكىٌ يىجىد بانتحانيم او األشعة‬, ‫انهي َالحظه‬

Words that reflect assessment

- Assess - Check - Collect - Determine - Find out - Gather - Identify - Monitor - Observe - Obtain
information – Recognize.

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Diagnosis: identifies human responses to actual or potential health problems

ٍ‫تحلُل شكىي المزَط وتحذَذ التشخُص التمزَع‬

planning: the nurse develops strategies to resolve or decrease the patient's problem
‫َحذد االستزاتُجُاث وخطت الزعاَت للتقلُل مه مشكلت المزَط‬

implementation: intervention& action ‫التىفُذ‬

evaluation :the nurse determine the effectiveness the plan of care.‫انًًرض يقيى فعانية خطة انرعاية‬

The clinic nurse prepares to develop a diabetic teaching program. To meet the clients’ needs,
the nurse should take which action first?

A. Assess the clients’ functional abilities.

B. Ensure that insurance will pay for participation in the program.
C. Discuss the focus of the program with the interprofessional team.
D. Include everyone who comes into the clinic in the teaching sessions

first‫الحظ في انسؤال انكهًة االستراتيجية‬

‫هُا راح َبحث شي يعكس يفهىو انتقييى؟‬

The client reports nausea and constipation. Which of the following would be the priority
nursing action?

A) Collect a stool sample

B) Complete an abdominal assessment

C) Administer an anti-nausea medication

D) Notify the physician

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The phase that include action of the nursing care plan is called:

A- Implementation

B- Assessment

C- Diagnosis
D- Evaluation

Identification and quantification of health problem in a community as a whole in term of

mortality and morbidity. Which of the following explains this phrase?

A. Diagnosis

B.Assessment

C. Participation

D. Involvement

Which of the following is correct nursing process order?

A. Diagnosis, assess, plan, evaluate, implement

B. Assess, diagnosis, plan, implement,evaluate

C. Evaluate, assess, plan, implement, diagnosis.

D. Plan, assess, diagnosis, evaluate, implement

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Which of the following is the most appropriate physical assessment of a patient with blunt
abdominal trauma?
A. Inspect, palpate, auscultate, percuss
B. Inspect, palpate, percuss, auscultate
C. Inspect, percuss, palpate, auscultate
D. Inspect, auscultate, palpate, percuss

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) Diagnosis

C) Planning

D) Evaluating

A client comes in a clinic with reports of abdominal pain and diarrhea. While taking the
client’svital signs, the nurse is implementing which phase of the nursing process?

A) Assessment

B) Diagnosis

C) planning

D) Implementation

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In taking care of patients for cardiac catheterization, the nurse noted that the patient
manifested fear related to cardiac catheterization and its outcome, this statement is an
example of:

A) Nursing diagnosis
B) Implementation
C) Evaluation
D) Intervention

A patient is recently diagnosed with Herpes Zoster. The nurse Establishing the care plan
would MOST likely assign the highest Priority to which of the following nursing Diagnosis?

A-Anxiety

B-Social Isolation

C-Peripheral neurovascular dysfunction

D-Acute pain

A community health nurse assess a 68 year old patient who lives in a group home. The
patient reports decreased appetite after transferring to the group home because the food
tastes too bland What type of data is the nurse collecting from the above information?
A-Analytical

B-Derived

C-Objective

D-Subjective

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A patient has pulmonary embolism. Which of the following nursing diagnoses has
PRORITY?

H.IN?GJoi. wd.uijd1daH
A-Anxiety related to pain, dyspnea, and concern of illness

B-Risk for injury related to altered hemodynamic status

C-Acute pain related to congestion and possible lung infarction

D-Ineffective breathing pattern related to acute increase in alveolar dead air space

A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should
receive the highest priority at this time?

UH
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 Jib
ID
D) Altered peripheral tissue perfusion related to venous congestion

The nurse is caring for a patient diagnosed with human immune Deficiency virus. Which of
the following nursing diagnoses takes Priority:

A-Diarrhea related to medication side effects

B-Risk for infection related to inadequate immune system

C-Imbalanced nutrition relate to decreased appetite

D-Impaired tissue integrity related to cachexia and Malnourishment

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DURING tonic clonic seizure patient is moving and has difficulty of breathing and cyanosis
,what is most appropriate nursing intervention ?
A-support arm and extremities
B- put off material under patient
C- put tongue depressed between teeth
D-take measures to prevent injury

The primary nurse in the cardiac nurse unit provided care for a patient with myocardial
infraction with chest pain ,which activity is related to nursing planning?
A- Adminisert morphine as prescribed
B- Assess the level of pain management
C- Clearly state the nursing diagnosis as pain
D- Determine a set of nursing intervention outcome for pain

A patient presents to the clinic with 3+ edema of the lower extremities, diagnosed neck
veins, tachycardia, bounding pulse, weight gain of 4 kilograms with 7 days, shortness of
breath, and wheezing. Fluid intake over the past 24 hours has been 3700ml output is
estimated at 2400ml. which of the following is the most likely nursing diagnosis?
A. Fluid volume excess
B. Urinary tract infection
C. Hypothyroidism
D. Ketoacidosis

A nurse is assigned to care for a patient with physical immobility due to right knee injury.
the nurse is preparing to write nursing diagnosis. Which of the following is a priority for
nursing diagnosis?
A. Pain
B. Hygiene
C. Dehydration
D. risk for impaired Skin integrity
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Alzheimer's patient high risk for Fall and admitted with fractures hip during hospitalization
the patient fell twice. What should the nurse do?
A. Continue same plan
B. Impair skin integrity
C. Risk for pressure ulcer
D. Non compliance add new nursing diagnosis

A 70 year-old woman is admitted to the Cardiac Care Unit with new onset atrial fibrillation
and is receiving intravenous diltiazem and heparin. What is the most likely nursing
diagnosis?
A. High risk for infection
B. High risk for impaired gas exchange
C. High risk for decreased cardiac output
D. High risk for disturbed sensory perception

A client with a blunt trauma underwent an exploratory lap repair an intra abdominal injury
closed. A nasogastric tube attached suction and two wound Hemovac abdominal drains. He
is receiving an intravenous infusion of Ringer’s lactate epidural with continuous morphine.
oliguria and four hour post develops hypotension, tachycardia, nausea. Which of the
following is the priority nursing diagnosis?
A. Nausea
B. Risk for infection
C. Deficient fluid volume
D. Impaired urinary elimination

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92year-old woman patient was brought to the Outpatient for the removal of stitches on her
left cheek which was treated nine days back after being involved in road traffic accident
She covers her face completely and requests to be seen by a female doctor. The site of the
wound was red, swollen and some pussy points were visible. She states that she did not
wash her face since her accident and kept her face covered all the time as she did not want
anyone to see it. What is the most appropriate nursing diagnosis ?
A. Hopelessness
B. Social isolation
C.acute pain
D.Chronic pain

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‫اشهز التشخُصاث التمزَعُت اللٍ تكزرث فٍ االختبار مع االمزاض‬

Most common nursing HX in SNLE Most common cases

Knowledge deficit-high risk behavior Bad habit like drinking,overeating,no exercise etc..

Risk of Impaired swallowing Post op ‫ بعذ انتخذير ال‬gag reflex absent

Ineffective airway clearance Accumulate sputum on the airway for ex pneumonia

Acute pain Surgical incision

Risk for infection Receiving immunosuppesent ,after burn,have immune

Decreased cardiac output Conginital heart diseases like cardiomegaly

Impaired physical mobility Fracture, immobile

Impaired skin integrity ‫نهي عُذهى يشاكم بانجهذ ايثهة‬

Burn,eczemia,wound ,bedsore etc..

Ineffective breathing pattern Pulmonary embolism ‫ورية رئىية‬

-body image disturbance ‫بعذ عًهية‬mastectomy

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Key test-taking strategies

Look for the strategic words

‫اوظز للكلماث المفتاحُه‬

Determine if the question presents a positive or negative event query

Avoid asking yourself the forbidden words“ ,Well, what if ?

‫الكلماث المقفلت‬

Eliminate Options Containing Closed-Ended Words

: ‫احذف الخُاراث التٍ تحتىٌ علً كلماث مقفله مثل‬

Some closed-ended words are Only,must,none,all,always and every etc..

: ‫غالبا الخُار اللٍ َحىٌ كلماث مفتىحه مثل‬

Options that contain open-ended words ,such as May,usually,normally,commonely or generally
‫بالغالب الخُار َحتىٌ علً كلمت مه هذٌ الكلماث غالبا َكىن الخُار الصحُح‬

Positive and Negative Event Queries

positive event query uses strategic words that ask you to select an option that is correct ;for example,

Which statement by a client indicates an understanding of the side effects of the prescribed medication‖?

A negative event query uses strategic words that ask you to select an option that is an incorrect item or

statement ;for example

“ Which statement by a client indicates a need for further teaching about the side effects of the prescribed
medications?

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The nurse is providing instructions to a client and the family regarding home care after right
eye cataract removal.Which statement by the client would indicate an understanding of the
instructions?(Positive query)

A. ―I should sleep on my left side‖.

B. ―I should sleep on my right side

C. ―I should sleep with my head flat‖.

D. ―I should not wear my glasses at any time

The nurse teaches skin care to a patient receiving external radiation therapy .Which
response from the patient indicates that the patient will need more education? NEGATIVE
QUERY

A. I will handle the area gently

B. I will wear lose-fitting clothing

C. I will avoid the use of deodorants and perfume

D. I will limit my exposure to the sun for only one hour daily

1. Select the question topic of question

2. Did the question ask about a positive or negative event?

3. Rephrase the question in a simplified way

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The nurse is assigned to care for four clients .In planning client rounds ,which
client should the nurse assess first?
A. A postoperative client preparing for discharge with a new medication
B. A client requiring daily dressing changes of a recent surgical incision
C. A client scheduled for a chest x-ray after insertion of a nasogastric tube

D. A client with asthma who requested a breathing treatment during the previous
shift

The nurse employed in an emergency department is assigned to triage clients

coming to the emergency department for treatment on the evening shift .The
nurse should assign priority to which client?

A. A client complaining of muscle aches ,a headache ,and history of seizures

B. A client who twisted her ankle when rollerblading and is requesting medication
for pain

C. A client with chest pain who states that he just ate Pizza that was made with a
very spicy sauce

D. A client with a minor laceration on the index finger sustained while cutting an
eggplant

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patient with severe diverticulitis had surgery for placement of Colostomy. The
patient is upset, crying and will not look at the Colostomy. Which of the following
would be the HIGHEST Priority nursing diagnosis at this time?
A.Knowledge deficit, colostomy care
B.body image disturbance
C.Self-care deficit, toileting
D.Alteration in comfort

The comatosed patient with NGT for feeding and positioned in low fowler.
The nurse enter the patient room. She found the patient in supine position. She
auscultated lung sound with diventure. What is the most appropriate nursing
diagnosis?

A. Risk for injury

B. Risk for aspiration due to NGT

c.risk for decreased cardiac out

d- body image disturbance

A 19-year-old boy has been hospitalized with fracture in upper and lower
extremities after accident then provided with casts for upper and lower limbs.
Which of these Nursing diagnoses should the nurse consider in the Nursing plan
of care According to his age?

A. Impaired social interaction

B. Alteration in body image

C. Risk for infection
D. Anxiety

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planning the care for a client who has pneumonia, the nurse collects data
and develops nursing diagnoses. Which of the following is an example of a
properly developed nursing diagnosis?
a. Ineffective health maintenance as evidenced by unhealthy habits
b. Ineffective airway clearance as evidenced by inability to clear secretions
c.Ineffective therapeutic regimen management due to smoking
d. Ineffective breathing pattern related to pneumonia

According to Maslow's hierarchy of needs, which nursing diagnosis has the

lowest priority for a client admitted to the intensive care unit with a diagnosis of
congestive heart failure?
a. Impaired urinary elimination
b. Ineffective airway clearance
c.Ineffective coping
d.Risk for body image disturbance

ASEESEEMENT BEFORE INTERVENTION

patient came to AED with chest pain ,restlessness ,the patient has cardiac
surgery before,he has some injuries on his body ,pulse 110 bpm, BP 110/70
mmhg , what is the most appropriate nursing action?

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A boy was riding his bike to school when he hit the curb .He fell and hurt his leg .
The school nurse was called and found him alert and conscious ,but in severe
pain with a possible fracture of the right femur .Which of the following is the
FIRST action that the nurse should take?

A. Immobilize the affected limb with a splint and ask him not to move.

B. Make a thorough assessment of the circumstances surrounding the accident.

C. Put him in semi-Fowler’s position for comfort.

D. Check the pedal pulse and blanching sign in both legs

Test-Taking Strategy :Use the ABCs—airway–breathing –circulation—as a guide

to direct you to the correct option and note the strategic word ,priority

AIRWAY :npo ,gag reflex ,breathing ,water after surgery ,dysphagia after stroke ,
airway

BREATHING :breath sounds ,o2 admin ,o2 status pulse ox ,raise hob,

incentive spirometry

CIRCULATION :(hr ,bp ,cpr ,fluid status( fluid deficit or overload ,)diarrhea ,
pulses, iv fluids ,tpn ,central lines ,bleeding hemorrhage)

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A client in a postpartum unit complains of sudden sharp chest pain and dyspnea .
The nurse notes that the client is tachycardia and the respiratory rate is elevated .
The nurse suspects a pulmonary embolism.

A patient is brought to the AED due to anaphylaxis ,what is the AED nurse
priority?

A-monitor the patient LOC

B-Protect the patient airway

C-provide psychological support

D- Administer medications as ordered

A client with a diagnosis of cancer is receiving morphine sulfate for pain .The
nurse should employ which priority action in the care of the client?
1. Monitor stools.
2. Encourage fluid intake.
3. Monitor urine output.
4. Encourage the client to cough and deep breath

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What’s the first intervention for a patient experiencing chest pain and a sp02 of
92%?
A. Administer morphine.
B. Administer oxygen.
C. Administer sublingual nitroglycerin.
D. Obtain an electrocardiogram

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