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NURS 153 >NURSING PROCESS FINAL EXAM 2025/QUESTIONS WITH CORRECT DETAILED ANSWERS WITH RATIONALES/LATEST UPDATE 2025/ALREADY GRADED A +/
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interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection.
physical examination. The caregiver reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. The caregiver uses results from the diagnostic and laboratory tests to establish a client database, not checking orders for tests.
evaluation or to force eye contact is inappropriate.
client problems. The caregiver should validate data before interpreting the data and making inferences. The caregiver is interpreting and validating client data, not professional standards.
the client to be as comfortable as possible when conducting an interview. Assessing a client while another member of the health care team is working would be distracting and is not the best time for an interview to take place.
Subjective data include client’s feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a client’s health status. In this question, the appearance of the wound and the client’s temperature are objective data. Pacing is an observable client behavior and is also considered objective data. MATCHING A caregiver is completing an assessment using the PQRST to obtain data about the client’s chest pain. Match the questions to the components of the PQRST that the caregiver will be using. a. Where is the pain located? b. What causes the pain? c. Does it come and go? d. What does the pain feel like? e. What is the rating on a scale of 0 to 10?
:B
a. To form a language that can be encoded only by caregivers b. To distinguish the caregiver’s role from the physician’s role c. To develop clinical judgment based on other’s intuition d. To help caregivers focus on the scope of medical practice CORRECT ANS:->>>: B The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish the caregiver’s role from that of the physician/health care provider and help caregivers focus on the scope of nursing practice (not medical) while fostering the development of nursing knowledge. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the client’s needs. A diagnosis is a clinical judgment based on information.
b. Risk for infection related to chest x-ray procedure c. Risk for deficient fluid volume related to dehydration d. Impaired gas exchange related to alveolar-capillary membrane changes CORRECT ANS:->>>: D The related to factor of alveolar-capillary membrane changes is accurately written because it is a client response to the disease process of pneumonia that the caregiver can treat. The related to factor should be the cause of the problem (nursing diagnosis) that a caregiver can address. The related to factors of dehydration and pneumonia are all medical diagnoses that the caregiver cannot change. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat.
and the client’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the caregiver proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation CORRECT ANS:->>>: A After a thorough assessment, the caregiver should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions; this is the diagnosis phase. The evaluation phase involves determining whether the goals were met and interventions were effective.
Disruption of tissue integrity is a possible cause or etiology of pain. A report of pain, headache, and discomfort are examples of things a client might say (subjective data or defining characteristics) that may lead a caregiver to select Acute pain as a nursing diagnosis.
has an actual infection. Infection can be a medical diagnosis as well as a collaborative problem. Staphylococcal leg infection is a medical diagnosis.