Lectures First Week

1.
During which part of the client interview would it be best for the nurse to ask,
"What's the weather forecast for today?"
You answered correctly: Introduction
Rationale: Asking about the weather initiates the social or introductory phase of the
interview and allows the nurse to begin an assessment of the client's mental status. The
goal is to develop rapport with the client at the beginning of the interview. In the body
the client responds to the nurse's questions. During the closing the nurse or the client
terminates the interview.
Cognitive Level: Application
Client Need: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Fundamentals
Strategy: Recall the 3 major stages of an interview that allow the nurse to collect data in
a systematic and efficient manner. Choose correctly by reasoning that in the beginning
of the interview the nurse develops rapport with the client, often with the use of social or
conversational items.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of nursing:
Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education,
p. 268.
2. The nurse is most likely to collect timely, specific information by asking which of
the following questions?
You answered incorrectly: "Where does it hurt?"

The correct answer was: "Would you describe what you are feeling?"
Rationale: This is an open-ended question that will elicit subjective data. The data
collected will reflect the client's current health status and human response(s) and should
generate specific information that can be used to identify actual and/or potential health
problems. Options 2 and 3 are more likely to elicit general, nonspecific information.
Option 4 may result in a brief, one-word response or nonverbal gesture indicating the
site of the client's pain. A better approach to collect specific information might be,
"Describe any pain you are having."
Strategy: The critical words are most likely and specific information. Recall the various
types of questions used to interview clients will aid in choosing correctly.
Concepts process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education,
p. 266.
3. The nurse should avoid asking the client which of the following leading questions
during a client interview?
You answered correctly: "You are really excited about the plastic surgery, aren't you?"
Rationale: A leading question directs the client's answer. The phrasing of the question
indicates an expected answer. The client may be influenced by the nurse's expectations
and may give inaccurate responses. This process can result in an error in diagnostic
reasoning.
Strategy: A critical term is leading question. Recall that the various types of questions
include leading, open ended, closed ended, and neutral. Use knowledge of the different
types of questions and the process of elimination to make a selection. Remember that
leading questions close communication.
p. 266.
4. The nurse needs to validate which of the following statements pertaining to an

assigned client?
You answered correctly: The client reported an infected toe.
Rationale: Validation is the process of confirming that data are actual and factual. Data
that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse
should assess the client's toe to validate the statement.
Strategy: The critical word is validate. Recall that the purpose of validation is to further
investigate a statement to ensure a valid assessment before drawing a clinical
inference. Use the process of elimination to choose the option that meets this purpose.
p. 274.
5. Which of the following items of subjective client data would be documented in the
medical record by the nurse?
You answered correctly: Client feels nauseated
Rationale: Subjective data includes the client's sensations, feelings, and perception of
health status. Subjective data can only be verified by the affected person. Options 1, 2,
and 3 represent objective data that can be detected by the nurse or measured against
an accepted norm.
Strategy: The critical term is subjective data. Recall the difference between subjective
and objective data, which is essential to answer the question. Recall that the client is the
"subject" and therefore data that is subjective comes from the client.
p. 274.
6. A nurse explains to a student that the nursing process is a dynamic process.

Which of the following actions by the nurse best demonstrates this concept during the
work shift?
You answered correctly: Nurse rapidly resets priorities for client care based on a change
in the client's condition
Rationale: The nursing process is characterized by unique properties that enable it to

respond to the changing health status of the client. Options 1, 2, and 3 are appropriate
nursing care measures, but do not demonstrate the dynamic nature of the nursing
process.
Client Need: Safe, Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Analysis
Strategy: The critical term is dynamic process. Recall that the term dynamic implies a
need to constantly evaluate the client's status and make needed changes in the plan of
care. This will help you to choose correctly.
p. 257.
7. The client reports nausea and constipation. Which of the following would be the
priority nursing action?
You answered incorrectly: Administer an anti-nausea medication

The correct answer was: Complete an abdominal assessment
Rationale: Assessment involves the systematic collection of data about an individual

upon which all subsequent phases of the nursing process are built. In response to a
client's complaint, a nurse assesses a specific body system to obtain data that will help
the nurse make a nursing diagnosis and plan the client's care. The other options reflect
interventions, which are not timely unless there is first a complete assessment.
Cognitive Level: Analysis
Client Need: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Strategy: A critical term is priority nursing action. Recall that the first step of the nursing
process is assessment, and that action is not generally taken with a single piece of data
unless further data is gathered to validate it. Use this logic and the process of
elimination to make a selection.
p. 261.
8. The nurse suspects that a client is withholding health-related information out of

fear of discovery and possible legal problems. The nurse formulates nursing diagnoses
for the client carefully, being concerned about a diagnostic error resulting from which of
the following?
You answered correctly: Incomplete data
Rationale: To collect data accurately, the client must actively participate. Incomplete
data can lead to inappropriate nursing diagnosis and planning. The other options are not
relevant to the question as presented.
Strategy: The critical words are withholding health-related information. Choose the
option that is the most logical consequence of the scenario presented in the stem of the
question.
p. 262.
9. The nurse notes that the client often sighs and says in a monotone voice, "I'm
never going to get over this." When encouraged to participate in care, the client says, "I
don't have the energy." The nurse believes these cues are suggestive of which nursing
diagnoses? Select all that apply.
You answered incorrectly: Hopelessness; Powerlessness; Self care deficit; Disturbed

self esteem
The correct answers were: Hopelessness; Powerlessness
Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or

potential health problem. This client is manifesting symptoms of both hopelessness and
powerlessness. Although the client does report symptoms compatible with fatigue, there
is no direct data is given that indicates the client has interrupted sleep patterns (option
3), disturbed self esteem (option 4), or self care deficit (option 5).
Strategy: Read the information in the stem and note the negative tone to the client's
words. Focus on the words don't have the energy as well. With these in mind, use the
process of elimination to select correctly.
Reference: Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of nursing;
concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson/Prentice
Hall, p. 285.
10. Which of the following descriptors is most appropriate to use when stating the
"problem" part of a nursing diagnosis?
You answered correctly: Anxiety
Rationale: The problem part of a nursing diagnosis should state the client's response to
a life process, event, or stressor. These are categorized as nursing diagnoses. The
incorrect options are cues the nurse would use to formulate the nursing diagnostic
statement.
Strategy: The critical phrases are problem part and nursing diagnosis. Use knowledge
of the steps of the nursing process and select the option that matches the definition
most accurately.
pp 279.
11. Which desired outcome written by the nurse is correctly written and measurable?
You answered correctly: The client will lose 4 pounds within the next 2 weeks.
Rationale: An outcome statement must describe the observable client behavior that
should occur in response to the nursing interventions. It consists of a subject, action
verb, conditions under which the behavior is to be performed, and the level at which the
client will perform the desired behavior. Each of the incorrect options lacks one of these
required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a
client goal. Option 4 does not include the level at which the behavior should be
performed.
Client Need: Safe Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Planning
Strategy: The critical terms are desired outcomes, correctly written, and measurable.
Knowledge of the appropriate components of goal statements is key to making a correct
selection.
p. 301.
12. The rehabilitation nurse wishes to make the following entry into a client's plan of
care: "Client will reestablish a pattern of daily bowel movements without straining within
two months." The nurse would write this statement under which section of the plan of
care?
You answered correctly: Long-term goals
Rationale: Long-term goals describe changes in client behavior expected over a time
frame greater than one week. They are usually designed to restore normal functioning in
a problem area and are helpful to other healthcare workers who care for the client, often
in a variety of settings.
Strategy: The critical terms are client will (which indicates a client goal because it is
action oriented and client-focused) and within 2 months (which is long term rather than
short term). Focus on these terms and use the process of elimination to make a
selection.
p. 301.
13. Which of these is a correctly stated outcome goal written by the nurse?
You answered correctly: The client will walk 2 miles daily by March 19.
Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate,

Realistic, and Timely. Option 1 is the only outcome that has a specific behavior (walks
daily), with measurable performance criteria (2 miles), and a time estimate for goal
attainment (by March 19).
Strategy: The critical term is correctly stated. Recall that the essential components of
client outcome goals will allow the nurse to set appropriate, timely and measurable
goals.
p. 302.
14. The nursing diagnosis is Risk for impaired skin integrity related to immobility and
pressure secondary to pain and presence of a cast. Which of the following desired
outcomes should the nurse include in the care plan?
You answered correctly: Skin will remain intact and without redness during hospital stay.
Rationale: The human response/label is what needs to change (Risk for impaired skin
integrity). The label suggests the outcomes. In this case, "skin will remain intact" is the
desired outcome for a client at risk for impaired skin integrity. Option 1 addresses
immobility. Option 3 addresses pain. Option 4 is an intervention.
Strategy: The critical term is outcomes. Focus on the important components of outcome
statements as well as the relation between the nursing diagnosis and the outcome to
select the best option for care planning.
p. 303.
15. While assisting a client from bed to chair, the nurse observes that the client looks
pale and is beginning to perspire heavily. The nurse would then do which of the
following activities as a reassessment?
You answered correctly: Observe client's skin color and take another set of vital signs
Rationale: Assessment is ongoing throughout the nurse-client relationship. During re-

assessment, the nurse collects additional data to help evaluate the status of problems
or identify new problems. Options 1, 2, and 3 are interventions.
Client Need: Physiological Integrity: Basic Care and Comfort
Integrated Process: Nursing Process: Assessment
Strategy: A critical term is reassessment. Be aware of the need for continuous
assessment as a key practice to implement safe nursing care. In this instance, the
correct answer provides additional data to the nurse about the client's condition.
p. 316.
16. After instructing the client on crutch walking technique, the nurse should evaluate
the client's understanding by using which of the following methods?
You answered correctly: Return demonstration
Rationale: Interpersonal skills are the sum of the activities the nurse uses when
communicating with others. Technical/psychomotor skills are "hands-on" skills, which
are often procedures and are evaluated by return demonstration. Cognitive skills are the
intellectual skills of analysis and problem-solving and are evaluated by tests.
Client Need: Physiological Integrity: Basic Care and Comfort
Integrated Process: Teaching and Learning
Strategy: Review teaching/learning principles.
Hall, p. 448.
17. The nurse would do which of the following during the implementation phase of
the nursing process when working with a hospitalized adult?
You answered incorrectly: Write individualized nursing orders in the care plan.
The correct answer was: Record in the medical record the distance a client ambulated
in the hall.
Rationale: The implementation phase of the nursing process involves carrying out or
delegating the nursing interventions and recording nursing activities and client
responses in the medical records. Option 1 represents diagnosing. Option 3 represents
planning. Option 4 represents evaluation.
Integrated Process: Nursing Process: Implementation
Strategy: Recall the components of each of the 5 phases of the nursing process. Recall
that implementation refers to actions to make the correct selection.
p. 317.
18. A client on the nursing unit is terminally ill but remains alert and oriented. Three
days after admission, the nurse observes signs of depression. The client states, "I'm
tired of being sick. I wish I could end it all." What is the most accurate and informative
way to record this data in a nursing progress note?
You answered correctly: Client states, "I'm tired of being sick. I wish I could end it all."
Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and

sensations that are apparent only to the person affected and cannot be measured,
seen, or felt by the nurse. This information should be documented using the client's
exact words in quotes. The other options indicate that the nurse has drawn the
conclusion that the client no longer wishes to live. From the data provided, the cues do
not support this assumption. A more complete assessment should be conducted to
determine if the client is suicidal.
Strategy: The critical words are most accurate and informative. Recall the importance of
documenting subjective data in the client's own words to help make the correct selection
from the available options.
Reference Kozier, B., Erb, G., Berman, A., Snyder, S. (2004). Fundamentals of nursing:
p. 274.
19. The nurse evaluates the client's progress and determines that one of the nursing
diagnoses on the client's care plan has been resolved. How should the nurse document
this so that it is best communicated to the healthcare team?
You answered incorrectly: Write a nursing progress note indicating that the outcome
goals have been achieved.
The correct answer was: Draw a single line through the diagnosis on the care plan and
write the nurse's initials and date.
Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a
single line or highlight it, then write initials and date. Some agency forms may require
the nurse to put date and initials in a "Date Resolved" column. Using Liquid PaperTM is
not a legal way to amend client records. Outcome goals that have been met and nursing
diagnoses that have been resolved should be documented on the care plan. A progress
note should also be written, but a single note may not be read by all health team
members.
Strategy: The critical phrase is best communicated to the healthcare team. Recall that it
is important to follow agency policy, which requires health care providers to date and
sign when a client problem is resolved.
p. 333.
20. The client is being discharged to a long-term care (LTC) facility. The nurse is
preparing a progress note to communicate to the LTC staff the client's outcome goals
that were met and those that were not. To do this effectively, the nurse should:
You answered incorrectly: Formulate post-discharge nursing diagnoses.

The correct answer was: Draw conclusion about resolution of current client problems.
Rationale: Terminal evaluation is done to determine the client's condition at the time of
discharge. This evaluation is best reflected in option 2 because it focuses on which
goals were achieved and which were not. Ongoing evaluation is done while or
immediately after implementing a nursing intervention. Intermittent evaluation is
performed at specified intervals, such as twice a week. Items related to care post-
discharge (options 2, 3, and 4) should be done on admission to the LTC facility.
Integrated Process: Nursing Process: Evaluation
Strategy: The core issue of the question is knowledge of actions to take as part of
nursing process at the time of hospital or agency discharge. Use this knowledge and the
process of elimination to make a selection.
Hall, p. 319.
21. A client who complains of nausea and seems anxious is admitted to the nursing
unit. The nurse should take which of the following actions regarding completion of the
admission interview?
You answered correctly: Do the interview as soon as some uninterrupted time is

available in order to address the client's concerns.
Rationale: To collect data accurately, the client must participate. Attending to the client's
immediate personal needs before expecting the client to focus on the interview will
maximize the accuracy of the data collected. Data should be collected shortly after
admission. The best source of data is the client. The management of the client's anxiety
is the responsibility of the nurse conducting the interview and initiating the relationship.
Client Need: Health Promotion and Maintenance
Strategy: The critical phrase is admission interview. Use knowledge of interview timing
and techniques to help eliminate the incorrect options, recalling that anxiety and other
forms of distress will not yield the best data.
concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson Education,
p. 266.
22. The nurse overhears an unlicensed assistive person (UAP) who has just been
accepted to nursing school say to a client, "You must be so pleased with your progress."
The nurse later explains to the UAP that this is an example of what type of question?
You answered correctly: Leading question

Rationale: A leading question is asked in a way that suggests the type of answer that is
expected. This can result in inaccurate data collection. A closed-ended question
generally requires only a "yes" or "no" or short factual answer. Open-ended questions
encourage clients to elaborate on their thoughts and feelings. Neutral questions do not
influence the client's answer.
Strategy: The core issue of the question is differentiating among the different types of
questions that can be used when communicating with a client. Recall that leading
questions are those that direct the client's response and should be used cautiously.
p. 266.
23. The nurse would do which of the following activities during the diagnosing phase
of the nursing process? Select all that apply.
You answered correctly: Analyze data; Identify problems, risks, and client strengths;
Develop nursing diagnoses
Rationale: The diagnosing phase of the nursing process involves data analysis, which
leads to identification of problems, risks, and strengths and the development of nursing
diagnoses. Collecting and organizing client data is done in the assessment phase of the
nursing process. Goal setting occurs during the planning phase.
Strategy: The critical words are diagnosing phase. Recall the activities associated with
each phase of the nursing process. Eliminate option 1 because it refers to assessment
and option 5 because goals are set during the planning phase of care.
Concepts, process, and practice (7th ed.). Upper Saddle River, NJ: Pearson/Prentice
Hall, p. 278.
24. The functional health pattern assessment data states: "Eats three meals a day
and is of normal weight for height." The nurse should draw which of the following
conclusions about this data? Select all that apply.
You answered incorrectly: Specific questions about the diet should be asked next;
Possible nursing diagnosis exists; Client has a wellness diagnosis
The correct answers were: Client has a wellness diagnosis; Specific questions about the
diet should be asked next
Rationale: The description indicates a healthy pattern of nutrition for the client. A
wellness diagnosis might be stated as: "Potential for enhanced nutrition." An actual
health problem is a client problem that is currently present. The nurse should also do a
diet assessment to determine the quality of the food eaten during meals. These actions
by the nurse are within the scope of independent nursing practice and are not
collaborative in nature.
Strategy: Choose option 2 first because the data in the question are normal. This
automatically eliminates options 2, 3, and 4. Reason that a client who eats 3 meals of
day and is of normal weight might not be eating foods in the proportions suggested in
MyPyramid to choose option 5.
p. 272.
25. For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral
fractured wrists in casts, what is the major related factor or risk factor identified by the
nurse?
You answered correctly: Fractured wrists
Rationale: The etiology or related factors of a nursing diagnostic statement define one
or more probable causes of the problem and allow the nurse to individualize the client's
care. In this case, the fracture is the cause of the client's feeding problem.
Strategy: The critical phrase is major related factor or risk factor. Nursing knowledge of
the key components of a nursing diagnosis is essential to answer the question. Recall
that the related or risk factor is identified immediately after the nurse diagnosis label to
help you choose correctly.
pp. 285-86.
26. The nurse would make which of the following inferences after performing the
appropriate client assessment?
You answered incorrectly: Client relays anxiety about blood work

The correct answer was: Client is hypotensive
Rationale: An inference is the nurse's judgment or interpretation of cues such as judging

a blood pressure to be lower than normal. A cue is any piece of data information that
influences a decision. Options 2, 3, and 4 are cues that could lead to inferences.
Strategy: The critical word is inferences. Recall that the ability to analyze data to make
correct inferences is the essence of critical thinking in nursing practice.
Hall, p. 282.
27. The nurse would write which of the following outcome statements for a client
starting an exercise program?
You answered correctly: Client will progress to walking a 20-minute mile in one month.
Rationale: Outcome statements must be written in behavioral terms and identify specific,
measurable client behaviors. They are stated in terms of the client with an action verb
that, under identified conditions, will achieve the desired behavior. They should also be
realistic and achievable.
Client Need: Health Promotion and Maintenance Integrated Process: Nursing Process:
Planning
Strategy: A critical term is outcome statement. Recall the essential components of client
outcome statements to choose correctly.
Hall, p. 302.
28. The nurse decides it would be beneficial to the client to allow the client's infant
granddaughter to visit before the client's scheduled heart transplant. Before
implementing this intervention the nurse should collaborate with which of the following?
Select all that apply.
You answered incorrectly: Client and family; Hospital administration; Other nursing staff
on the unit
The correct answers were: Client and family; Other nursing staff on the unit
Rationale: Collaboration with the client and family will encourage a sense of autonomy
and active involvement in the healthcare process for the client. In this case collaboration
with other nursing staff will ensure the successful implementation of the planned
intervention. There is no real need for collaboration with hospital administration or the
security department in this situation although the nurse should be aware of her
responsibility to collaborate at those levels when the situation demands it.
Strategy: The critical term is collaborate. The complexity of care planning necessitates
frequent collaboration with others to provide optimal client care.
Hall, p. 305.
29. The nurse informs the physical therapy department that the client is too weak to
use a walker and needs to be transported by wheelchair. Which step of the nursing
process is the nurse engaged in at this time?
You answered correctly: Implementation
Rationale: The nurse is responsible for coordinating the plan of care with other
disciplines to ensure the client's safety. This action represents the implementation phase
of the nursing process. Data gathering occurs during assessment. Goal setting occurs
during planning. Determining attainment of client goals occurs as part of evaluation.
Strategy: The critical phrase is which step of the nursing process. Use the process of
elimination and knowledge of the steps of the nursing process to make a selection.
Hall, p. 318.
30. A desired outcome for a client immobilized in a long leg cast reads; Client will
state three signs of impaired circulation prior to discharge. When the nurse evaluates
the client's progress, the client is able to state that numbness and tingling are signs of
impaired circulation. What would be an appropriate evaluation statement for the nurse to
write?
You answered incorrectly: Goal met: Client cited numbness and tingling as signs of
impaired circulation.
The correct answer was: Goal not met: Client able to name only two signs of impaired
circulation.
Rationale: The goal has not been met because the client states only two out of three
signs of impaired circulation. By comparing the data with the expected outcomes, the
nurse judges that while there has been progress toward the goal, it has not been
completely met. The care plan may need to be revised or more effective teaching
strategies may need to be implemented to achieve the goal.
Strategy: The critical phrase is three signs. Recall that the evaluation statement must
state whether or not the goal was met and summarize the results of interventions.
Evaluate each option in light of the information in the stem of the question and use the
process of elimination to make a selection.
Hall, p. 320.

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1.

You answered correctly: Introduction

You answered incorrectly: "Where does it hurt?"

4. The nurse needs to validate which of the following statements pertaining to an

You answered correctly: The client reported an infected toe.

You answered correctly: Client feels nauseated

6. A nurse explains to a student that the nursing process is a dynamic process.

Rationale: The nursing process is characterized by unique properties that enable it to

You answered incorrectly: Administer an anti-nausea medication

Rationale: Assessment involves the systematic collection of data about an individual

8. The nurse suspects that a client is withholding health-related information out of

You answered correctly: Incomplete data

You answered incorrectly: Hopelessness; Powerlessness; Self care deficit; Disturbed

Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or

You answered correctly: Anxiety

You answered correctly: Long-term goals

Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate,

Rationale: Assessment is ongoing throughout the nurse-client relationship. During re-

You answered correctly: Return demonstration

Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and

You answered incorrectly: Formulate post-discharge nursing diagnoses.

You answered correctly: Do the interview as soon as some uninterrupted time is

You answered correctly: Leading question

You answered correctly: Fractured wrists

You answered incorrectly: Client relays anxiety about blood work

Rationale: An inference is the nurse's judgment or interpretation of cues such as judging

You answered correctly: Implementation

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