Practice Quiz Answers

Unit 5

Question 1

Which of the following is an appropriately written nursing diagnosis?

A) Pain related to insufficient use of medication

B) Pain related to difficulty ambulating
C) Anxiety related to cardiac monitor
D) Bedpan required frequently as a result of altered elimination pattern

Correct Answer: A

Explanation: A. This is an example of an appropriately written nursing diagnosis. It consists of a

diagnostic label and the associated etiology. Nursing interventions can be directed at treating or
managing the behavior of insufficient medication use. (note: for purposes of this example there
are no signs and symptoms listed. In an actual diagnosis the S/S would need to be listed as well.)
B. This nursing diagnosis is not written correctly. What could be a defining characteristic (S/S) is
used as an etiology. This nursing diagnosis could be rewritten more appropriately as Impaired
mobility related to pain as evidenced by difficulty ambulating.
C. This nursing diagnosis is written incorrectly because it identifies the equipment rather than the
client’s response to the equipment. It would be appropriate to state deficient knowledge regarding
the need for cardiac monitoring.
D. This nursing diagnosis is written incorrectly because it identifies a nursing intervention, not the
client’s problem. It could be reworded, Diarrhea related to food intolerance for example.

Question 2

Accountability is a critical aspect of nursing care. An example of accountability is demonstrated

by:

A) Selecting the medication schedule for the client

B) Implementing discharge teaching plans that meet individual needs
C) Evaluating the client's outcomes after implementation of care
D) Promoting participation of all staff members in unit meetings

Correct Answer: C

Explanation: C: Accountability refers to individuals being answerable for their actions. It involves
follow-up and a reflective analysis of one’s decisions to evaluate their effectiveness.
A. Selecting the medication schedule for the client is an example of taking responsibility.
B. Implementing discharge-teaching plans that meet individual needs is an example of autonomy.

D. Promoting participation of all staff members in unit meetings is an example of promoting

authority.
Question 3

The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The
client tells the nurse she wants to have her hair shampooed. How would the nurse prioritize this
client need?

A) Immediate priority
B) High priority
C) Intermediate priority
D) Low priority

Correct Answer: D

Explanation: D. The client’s request would be of low priority because it is not directly related to a
specific illness or prognosis.
B. The client’s request is not a high priority. It is not a life-threatening situation.
C. The client’s request is not an intermediate priority. An intermediate priority is one that involves
the nonemergency, non–life threatening needs of the client.
A. The client’s request is not an immediate priority. It is not a life-threatening situation.

Question 4

Nursing interventions should be documented according to specific criteria so they are clearly
understood by other members of the nursing team. The most appropriate of the following
intervention statements is:

A) Offer fluids to the client q 2 hours

B) Observe the client's respirations
C) Change the client's dressing daily
D) Irrigate the nasogastric tube q 2 hours with 30 mL normal saline

Correct Answer: D

Explanation: D: This is the most appropriate intervention statement. It includes the action,
frequency, quantity, and method.
A. This intervention statement lacks the component of quantity.
B. This intervention statement fails to indicate the frequency or method (i.e., what is the nurse
specifically looking for?).
C. This intervention statement omits the method.

Question 5

A nurse who specializes in care of clients with ostomies shows a client's significant other how to
assist with the manipulation of ostomy equipment. The nurse demonstrating the technique to the
client is using what type of nursing skill?
A) Cognitive
B) Interactive
C) Affective
D) Psychomotor

Correct Answer: D

Explanation: D: Psychomotor skills involve the integration of cognitive and motor activities, such
as in providing ostomy care.
A. Cognitive skills involve the application of nursing knowledge. Knowing the rationale for
therapeutic interventions, understanding normal and abnormal physiological and psychological
responses, and being able to identify client learning and discharge needs all require cognitive
skills.
B. Interpersonal skills are used when the nurse interacts with clients, their families, and other
health care team members. Effective communication is an example of an interpersonal skill.
C. Affective means pertaining to an emotion or mental state.

Question 6

During an interview, the nurse needs to obtain specific information about the signs and symptoms
of a health problem. To obtain these data most efficiently, the nurse should use:

A) Active listening
B) Open-ended questions
C) Closed-ended questions
D) Seeking clarification

Correct Answer: C

Explanation: C: Using closed-ended questions helps the nurse to acquire specific information
about health problems such as symptoms, precipitating factors, or relief measures in an efficient
manner.
A. Active listening occurs when the nurse uses techniques such as “all right,” “go on,” or “uh-huh,”
to indicate that the nurse has heard what the client said and to encourage the client to elaborate
further.
B. Using open-ended questions prompts the client to describe a situation in more than one or two
words. Because it allows the client the opportunity to tell his or her story and reveal what is
important, it is not the most efficient method of obtaining specific information regarding a client’s
signs and symptoms of a health problem.
D. In seeking clarification, the nurse attempts to make the broad meaning of the message more
understandable. The nurse can restate or repeat the client’s message.

Question 7

Which of the following is classified as subjective data?

A) Client appears sleepy

B) No distress noted
C) Abdomen soft and non-tender
D) States feels anxious and tense
Correct Answer: D

Explanation: D: Subjective data are clients' perceptions about their health problems. Feeling
anxious and tense is information that only the client can provide.
a. Objective data are observation or measurements made by the data collector. In this example,
the nurse is making the observation that the client appears sleepy.
b. “No distress noted” is an example of objective data because it is an observation made by the
nurse.
c. “Abdomen soft and non-tender” is an example of objective data because it is an observation
made by the nurse, not a client’s perception.

Question 8

The nurse uses a variety of skills in the application of the nursing process. An example of a
cognitive nursing skill is:

A) Providing a soothing bed bath

B) Communicating with the client and family
C) Giving an injection to the client per physician’s orders
D) Recognizing the potential complications of a blood transfusion

Correct Answer: D

Explanation: D: Cognitive skills involve the application of nursing knowledge. Understanding

normal and abnormal physiological and psychological responses is a cognitive skill, as in
recognizing the potential complications of a blood transfusion.
A. Providing a soothing bed bath involves both interpersonal skills and psychomotor skills. The
nurse who provides a soothing bed bath is expressing a level of caring, which is an interpersonal
skill. The nurse who provides a soothing bed bath also is using a psychomotor skill in performing
the bed bath correctly.
B. Communicating with the client and family is an example of an interpersonal skill.
C. Giving an injection to the client is a psychomotor skill.

Question 9

Which of the following is an appropriate etiology for a nursing diagnosis?

A) Incisional pain
B) Poor hygienic practices
C) Needs bedpan frequently
D) Inadequate prescription of medication by the physician

Correct Answer: A

Explanation: A. Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition

that identifies the cause of a client’s response to a health problem that a nurse can treat or
manage.
B. “Poor hygiene practices” would not be an appropriate etiology for a nursing diagnosis because
it insinuates a nurse’s prejudicial judgment.
C. “Needs bedpan frequently” is not an appropriate etiology because it identifies a nursing
intervention, not an etiology.
D. “Inadequate prescription of medication by the physician” is not an appropriate etiology
because it identifies the nurse’s problem, not the client’s problem. The nursing diagnosis should
center attention on client needs.

Question 10

Nursing interventions should be documented according to specific criteria so they are clearly
understood by other members of the nursing team. The intervention statement “Nurse will apply
warm, wet soaks to the client's leg while the client is awake” lacks which of the following
components?

A) Method
B) Quantity
C) Frequency
D) Qualifications of the person who will perform the task

Correct Answer: C

Explanation: The intervention statement does not include how frequently the warm soaks should
be applied.
A. The method is applying warm wet soaks to the patient’s leg while the patient is awake.
B. The quantity is warm wet soaks.
D. The qualification of the person who will perform the action is the designation of “the nurse.”

Question 11

Of the following statements, which one is an example of an appropriately written nursing

diagnosis?

A) Acute pain related to left mastectomy

B) Impaired gas exchange related to altered blood gases
C) Deficient knowledge related to need for cardiac catheterization
D) Need for high protein diet related to alteration in nutrition

Correct Answer: C

Explanation: C: This nursing diagnosis is written correctly. It defines a problem and its possible
cause; in this case, the problem is the client’s response to a diagnostic test.
a. A medical diagnosis should not be recorded as an etiology because nursing interventions
cannot change the medical diagnosis. It would be appropriate to state Acute pain related to
impaired skin integrity secondary to mastectomy incision.
b. This nursing diagnosis is written incorrectly because it uses supportive data of the problem as
an etiology.
d. This nursing diagnosis does not identify the problem and etiology. It identifies the client’s goal
rather than the problem. It could be reworded as Imbalanced nutrition: less than body
requirements related to inadequate protein intake.

Question 12

The nurse notes a narcotic is to be administered per epidural cath. The nurse, however, does not
know how to perform this procedure. Which aspects of the implementation process should be
followed?

A) Seek assistance
B) Reassess the client
C) Use interpersonal skills
D) Critical decision making

Correct Answer: A

Explanation: A: If a nurse does not know how to perform a procedure, he or she should seek
assistance. Information about the procedure is obtained from the literature and the agency’s
procedure book. All equipment necessary for the procedure is collected. Finally, another nurse
who has completed the procedure correctly and safely provides assistance and guidance.
B. Reassessing the client is a partial assessment that may focus on one dimension of the client or
on one system. It provides a way to determine whether the proposed nursing action is still
appropriate for the client’s level of wellness.
C. Interpersonal skills are used to develop a trusting relationship, express a level of caring, and
communicate clearly with the client, family, and health care team.
D. Critical decision making is used when the nurse implements the care plan by using the
knowledge bases necessary for care planning and for then completing the planned interventions
most effectively. In this case, the nurse lacks the necessary knowledge and experience and
should seek assistance.

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