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Nursing Process: A Comprehensive Examination with Rationales, Exams of Nursing

Napa Valley College Nursing

A series of multiple-choice questions focused on the nursing process, covering key aspects like assessment, diagnosis, planning, implementation, and evaluation. Each question includes a detailed rationale explaining the correct answer, enhancing understanding and critical thinking skills. it's a valuable resource for nursing students preparing for exams, reinforcing their knowledge of the nursing process and its practical application in patient care. The questions cover various aspects of data collection, analysis, and decision-making within the nursing process framework.

Typology: Exams

2024/2025

Available from 05/08/2025

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NURS 153-NURSING PROCESS FINAL EXAM ||2025-

2026||QUESTIONS WITH CORRECT DETAILED ANSWERS

WITH RATIONALE. GRADED A +

1.

The caregiver is using critical thinking skills during the first phase of the nursing

process. Which action indicates the caregiver is in the first phase?

a.

Completes a comprehensive database

b.

Identifies pertinent nursing diagnoses

c.

Intervenes based on priorities of client care

d.

Determines whether outcomes have been achieved

CORRECT ANS:->>>: A

Rationale: The assessment phase of the nursing process involves data collection to complete

a thorough client database and is the first phase. Identifying nursing diagnoses occurs during

the diagnosis phase or second phase. The caregiver carries out interventions during the

implementation phase (fourth phase), and determining whether outcomes have been achieved

takes place during the evaluation phase (fifth phase) of the nursing process.

2.

A caregiver is using the problem-oriented approach to data collection. Which

action will the caregiver take first?

a.

Complete the questions in chronological order.

b.

Focus on the client’s presenting situation.

c.

Make accurate interpretations of the data.

d.

Conduct an observational overview.

CORRECT ANS:->>>: B

Rationale: A problem-oriented approach focuses on the client’s current problem or

presenting situation rather than on an observational overview. The database is not always

completed using a chronological approach if focusing on the current problem. Making

Partial preview of the text

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NURS 153-NURSING PROCESS FINAL EXAM || 2025 -

2026||QUESTIONS WITH CORRECT DETAILED ANSWERS

WITH RATIONALE. GRADED A +

The caregiver is using critical thinking skills during the first phase of the nursing process. Which action indicates the caregiver is in the first phase? a. Completes a comprehensive database b. Identifies pertinent nursing diagnoses c. Intervenes based on priorities of client care d. Determines whether outcomes have been achieved CORRECT ANS:->>>: A Rationale: The assessment phase of the nursing process involves data collection to complete a thorough client database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The caregiver carries out interventions during the implementation phase (fourth phase), and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process.
A caregiver is using the problem-oriented approach to data collection. Which action will the caregiver take first? a. Complete the questions in chronological order. b. Focus on the client’s presenting situation. c. Make accurate interpretations of the data. d. Conduct an observational overview. CORRECT ANS:->>>: B Rationale: A problem-oriented approach focuses on the client’s current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making

interpretations of the data is not data collection. Data

behavior, and measuring blood pressure are examples of objective data. States “doesn’t feel good,” reports a headache, and nausea are all subjective data. Subjective data include the client’s feelings, perceptions, and reported symptoms. Only clients provide subjective data relevant to their health condition.

A client expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the caregiver infer from the subjective data? a. The client can now perform the dressing changes without help. b. The client can begin retaking all of the previous medications. c. The client is apprehensive about discharge. d. The client’s surgery was not successful. CORRECT ANS:->>>: C Rationale: Subjective data include expressions of fear of going home and being alone. These data indicate (use inference) that the client is apprehensive about discharge. Expressing fear is not an appropriate sign that a client is able to perform dressing changes independently. An order from a health care provider is required before a client is taught to resume previous medications. The caregiver cannot infer that surgery was not successful if the incision is nearly completely healed.
Which method of data collection will the caregiver use to establish a client’s database? a. Reviewing the current literature to determine evidence-based nursing actions b. Checking orders for diagnostic and laboratory tests c. Performing a physical examination d. Ordering medications CORRECT ANS:->>>: C Rationale: You will learn to conduct different types of assessments: the client-centered interview during a nursing health history, a physical examination, and the periodic

assessments you make during rounding or administering care. A nursing database includes a 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.

A caregiver is gathering information about a client’s habits and lifestyle patterns. Which method of data collection will the caregiver use that will best obtain this information? a. Carefully review lab results. b. Conduct the physical assessment. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview. CORRECT ANS:->>>: C Rationale: The nursing health history also includes a description of a client’s habits and lifestyle patterns. Lab results and physical assessment will not reveal as much about the client’s habits and lifestyle patterns as the nursing health history. Collecting data is part of the working phase of the interview.
While interviewing an older female client of Asian descent, the caregiver notices that the client looks at the ground when CORRECT ANS:->>>wering questions. What should the caregiver do? a. Consider cultural differences during this assessment. b. Ask the client to make eye contact to determine her affect. c. Continue with the interview and document that the client is depressed. d. Notify the health care provider to recommend a psychological evaluation. CORRECT ANS:->>>: A Rationale: To conduct an accurate and complete assessment, consider a client’s cultural background. This caregiver needs to practice culturally competent care and appreciate the

client to elaborate on the daytime fatigue or ask about the contributing reasons. 11.A caregiver is conducting a nursing health history. Which component will the caregiver address? a. Caregiver’s concerns b. Client expectations c. Current treatment orders d. Caregiver’s goals for the client CORRECT ANS:->>>: B Some components of a nursing health history include chief concern, client expectations, spiritual health, and review of systems. Current treatment orders are located under the Orders section in the client’s chart and are not a part of the nursing health history. Client concerns, not caregiver’s concerns, are included in the database. Goals that are mutually established, not caregiver’s goals, are part of the nursing care plan.

While the client’s lower extremity, which is in a cast, is assessed, the client tells the caregiver about an inability to rest at night. The caregiver disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the caregiver to take? a. Tell the client to just focus on the leg and cast right now. b. Document the sleep patterns and information in the client’s chart. c. Explain that a more thorough assessment will be needed next shift. d. Ask the client about usual sleep patterns and the onset of having difficulty resting. CORRECT ANS:->>>: D The caregiver must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the client about usual sleep patterns and the onset of having difficulty resting. The caregiver should assess before documenting and should not ignore the client’s report of a problem or postpone it till the

next shift.

The caregiver begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a client who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the caregiver using? a. Gordon’s Functional Health Patterns b. Activity-exercise pattern assessment c. General to specific assessment d. Problem-oriented assessment CORRECT ANS:->>>: D The caregiver is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the caregiver focuses immediately on the problem at hand (dressing and drainage from surgery) and performs a problem-oriented assessment. Utilizing Gordon’s Functional Health Patterns is an example of a structured database-type assessment technique that includes 11 patterns to assess. The caregiver in this question is performing a specific problem-oriented assessment approach, not a general approach. The caregiver is not performing an activity-exercise pattern assessment in this question.
Which statement by a caregiver indicates a good understanding about the differences between data validation and data interpretation? a. “Data interpretation occurs before data validation.” b. “Validation involves looking for patterns in professional standards.” c. “Validation involves comparing data with other sources for accuracy.” d. “Data interpretation involves discovering patterns in professional standards.” CORRECT ANS:->>>: C

The caregiver should further assess and ask the client to describe the type of reaction. The client will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the client suffered.

A client verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the caregiver’s initial action in response to these observations? a. Proceed to the next client’s room to make rounds. b. Determine the client does not want any pain medicine. c. Ask the client about the facial grimacing with movement. d. Administer the pain medication ordered for moderate to severe pain. CORRECT ANS:->>>: C First, the caregiver needs to clarify/verify what was observed with what the client states. Proceeding to the next room is ignoring this visual cue. The caregiver cannot assume the client does not want pain medicine just because he reports a 2 out of 10 on the pain scale. The caregiver should not administer medication for moderate to severe pain if it is not necessary.
The caregiver is interviewing a client with a hearing deficit. Which area should the caregiver use to conduct this interview? a. The client’s room with the door closed b. The waiting area with the television turned off c. The client’s room before administration of pain medication d. The waiting room while the occupational therapist is working on leg exercises CORRECT ANS:->>>: A

Distractions should be eliminated as much as possible when interviewing a client with a hearing deficit. The best place to conduct this interview is in the client’s room with the door closed. The waiting area does not provide privacy. Pain can sometimes inhibit someone’s ability to concentrate, so before pain medication is administered is not advisable. It is best for 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.

A new caregiver is completing an assessment on an 80 - year-old client who is alert and oriented. The client’s daughter is present in the room. Which action by the caregiver will require follow-up by the charge caregiver? a. The caregiver makes eye contact with the client. b. The caregiver speaks only to the client’s daughter. c. The caregiver leCORRECT ANS:->>> forward while talking with the client. d. The caregiver nods periodically while the client is speaking. CORRECT ANS:->>>: B Gathering data from family members is acceptable, but when a client is able to interact, caregivers need to include information from the older adult to complete the assessment. Therefore, the charge caregiver must correct this misconception. When assessing an older adult, caregivers need to listen carefully and allow the client to speak. Positive nonverbal communication, such as making eye contact, nodding, and leaning forward, shows interest in the client. Thus, the charge caregiver does not need to intervene or follow up. MULTIPLE RESPONSE
A caregiver is completing an assessment. Which findings will the caregiver report as subjective data? (Select all that apply.) a. Client’s temperature b. Client’s wound appearance

ANS:-

>>>:B

2.CORRE

CT

ANS:-

>>>:D

3.CORRE

CT

ANS:-

>>>:A

4.CORRE

CT

ANS:-

>>>:E

5.CORRE

CT

ANS:-

>>>:C

Set 2

After assessing a client, a caregiver develops a standard formal nursing diagnosis. What is the rationale for the caregiver’s actions? 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.
Which diagnosis will the caregiver document in a client’s care plan that is NANDA-I approved? a. Sore throat b. Acute pain c. Sleep apnea d. Heart failure CORRECT ANS:->>>: B Acute pain is the only NANDA-I approved diagnosis listed. Sleep apnea and heart failure are medical diagnoses, and sore throat is subjective data.
A caregiver develops a nursing diagnostic statement for a client with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing

A caregiver is using assessment data gathered about a client and combining critical thinking to develop a nursing diagnosis. What is the caregiver doing? a. Assigning clinical cues b. Defining characteristics c. Diagnostic reasoning d. Diagnostic labeling CORRECT ANS:->>>: C Diagnostic reasoning is defined as a process of using the assessment data gathered about a client to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Defining characteristics are the subjective and objective clinical cues, which a caregiver gathers intentionally and unintentionally. The caregiver organizes all of the client’s data into meaningful and usable data clusters, which lead to a diagnostic conclusion. Diagnostic labeling is simply the name of the diagnosis.
A client presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the client has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the caregiver will include in the plan of care? a. Posttrauma syndrome b. Constipation c. Acute pain d. Anxiety CORRECT ANS:->>>: C Based on the assessment data provided, the only supportive evidence for one of the diagnosis options is “Reports only moderate discomfort,” which would support Acute pain. No supportive evidence is provided for any of the other diagnoses. The client may indeed develop signs or symptoms of the other problems, but supportive data are presently lacking in

the provided information.

The caregiver is reviewing a client’s database for significant changes and discovers that the client has not voided in over 8 hours. The client’s kidney function lab results are abnormal, 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.
A client with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health caregivers and family members. The caregiver adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the caregiver write? a. Risk b. Problem focused c. Health promotion d. Collaborative problem CORRECT ANS:->>>: C A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and actualize human health potential. A problem-focused nursing diagnosis describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an

c. Abdominal distention d. Constipation CORRECT ANS:->>>: C Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor. Constipation (problem or NANDA-1 diagnosis) is the identified problem derived from the defining characteristics.

The client database reveals that a client has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the caregiver identify as defining characteristics for the diagnostic label of Activity intolerance? a. Decreased oral intake and decreased oxygen saturation when ambulating Decreased oxygen saturation when ambulating and reports of shortness of breath b. when getting out of bed c. Reports of shortness of breath when getting out of bed and a productive cough d. Productive cough and decreased oral intake CORRECT ANS:->>>: B There are defining characteristics (observable assessment cues such as client behavior, physical signs) that support each problem-focused diagnostic judgment. The signs and symptoms, or defining characteristics, for the diagnosis Activity intolerance include decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed. The key to supporting the diagnosis of Activity intolerance is that only these two characteristics involve how the client tolerates activity. Decreased oral intake and productive cough do not define activity intolerance.
A caregiver performs an assessment on a client. Which assessment data will the caregiver use as an etiology for Acute pain? a. Discomfort while changing position

b. Reports pain as a 7 on a 0 to 10 scale c. Disruption of tissue integrity d. Dull headache CORRECT ANS:->>>: C 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.

A new caregiver writes the following nursing diagnoses on a client’s care plan. Which nursing diagnosis will cause the caregiver manager to intervene? a. Wandering b. Hemorrhage c. Urinary retention d. Impaired swallowing CORRECT ANS:->>>: B Hemorrhage is a collaborative problem, not a nursing diagnosis; the caregiver manager will need to correct this misunderstanding with the new caregiver. Caregivers manage collaborative problems such as hemorrhage, infection, and paralysis using medical, nursing, and allied health (e.g., physical therapy) interventions. Wandering, urinary retention, and impaired swallowing are all examples of nursing diagnoses.
A client has a bacterial infection in left lower leg. Which nursing diagnosis will the caregiver add to the client’s care plan? a. Infection b. Risk for infection c. Impaired skin integrity d. Staphylococcal leg infection

Nursing Process: A Comprehensive Examination with Rationales, Exams of Nursing

Related documents

Partial preview of the text

Download Nursing Process: A Comprehensive Examination with Rationales and more Exams Nursing in PDF only on Docsity!

NURS 153-NURSING PROCESS FINAL EXAM || 2025 -

2026||QUESTIONS WITH CORRECT DETAILED ANSWERS

WITH RATIONALE. GRADED A +

ANS:-

>>>:B

2.CORRE

CT

ANS:-

>>>:D

3.CORRE

CT

ANS:-

>>>:A

4.CORRE

CT

ANS:-

>>>:E

5.CORRE

CT

ANS:-

>>>:C