Nursing Process 2

Question 1

A nurse is performing an initial assessment on a newly admitted client.
The client reports chronic back pain and mentions they have been taking ibuprofen daily for 6 months.
Which follow-up assessment is most important?

Accepted Answer

Assess the client's stool color and frequency for signs of GI bleeding

Answer

Ask the client about their activity level and exercise habits

Answer

Inquire about the client's diet and nutritional status

Answer

Ask whether the client has tried physical therapy

Question 2

A nurse is developing a care plan for a client with diabetes who has a non-healing wound on the left foot. Which nursing diagnosis is most appropriate?

Accepted Answer

Risk for infection related to hyperglycemia and impaired wound healing

Answer

Disturbed body image related to visible wound on the foot

Answer

Deficient knowledge related to diabetes management

Answer

Ineffective health maintenance related to non-compliance with medication

Question 3

A nurse has implemented a plan of care for a client with fluid volume excess. The client's weight has increased by 2 kg over the past 24 hours and breath sounds show new bilateral crackles. In which step of the nursing process is the nurse currently engaged?

Accepted Answer

Evaluation

Answer

Assessment

Answer

Planning

Answer

Implementation

Question 4

A nurse is planning care and setting priorities for four clients. Using the nursing process, which client should be seen first?

Accepted Answer

A client with new onset confusion and a blood pressure of 80/50 mmHg

Answer

A client with hypertension requesting education on a low-sodium diet

Answer

A client post-op day 2 after cholecystectomy reporting incision pain of 5/10

Answer

A client with type 2 diabetes who needs their morning insulin administered

Question 5

A nurse formulates the nursing diagnosis: 'Impaired skin integrity related to immobility as evidenced by a 2 cm x 2 cm Stage 2 pressure injury on the sacrum.' Which part represents the 'etiology' component?

Accepted Answer

Immobility

Answer

Impaired skin integrity

Answer

A 2 cm x 2 cm Stage 2 pressure injury on the sacrum

Answer

Related to

Question 6

A nurse is collecting data on a newly admitted client. The client reports feeling anxious and states their heart is racing. The nurse observes the client is diaphoretic and notes a heart rate of 118 bpm. Which data are objective?

Accepted Answer

The heart rate of 118 bpm and visible diaphoresis

Answer

The client's report of feeling anxious and heart racing

Answer

All data collected during a nursing assessment

Answer

Only data obtained through laboratory analysis