Chapter 5 PrepU

1. A client presents to the emergency department following an accident at a construction site. The
client is bleeding profusely from a deep wound on his head and states he cannot feel his leg.
The nurse notes that the client is lethargic and mildly confused. What subjective data should the
nurse document on this client?
a. Unable to feel his leg
2. The nurse is grouping subjective and objective data. Which data would the nurse list as
subjective?
a. headaches began 3 days ago
3. The nurse is determining a priority problem that would be appropriate for a client with heart
failure. Which problem would have the highest priority for the client?
a. Weight gain of 3 pounds (1.5 kilograms) over 1-2 days
4. The nurse has completed a plan of care for a client having a total knee replacement. In order to
develop goals which are realistic for the client, what should the nurse do prior to implementing
the plan?
a. Ask the client for opinions and willingness to proceed with the interventions.
5. The nurse has learned that after completing the assesment phase of the nursing process, the next
step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do?
a. Analyze the data
6. A nursing student demonstrates understanding of the different types of nursing problems when
choosing the following to indicate that the patient has the opportunity for an enhanced health
state:
a. wellness diagnosis
7. A nursing student demonstrates understanding of the different types of nursing diagnoses when
choosing which of the following to be an actual diagnosis?
a. impaired skin integrity
8. A nursing instructor is teaching about diagnostic reasoning and the importance of culture. The
student needs further explanation when making which statement?
a. "All patients have the same defining characteristics."
9. The nursing student understands that data analysis is referred to as the diagnostic phase because
the end result is the identification of which of the following?
a. nursing diagnosis
10. The nurse recognizes that the second step or phase of the nursing process is difficult. Why is
data analysis a difficult step?
a. Diagnostic reasoning skills are required to interpret data accurately.
11. What can the nurse use to learn new information and add to their knowledge base?
a. Clinical experience.
12. A nurse is working with a patient who has a history of chronic obstructive pulmonary disease
(COPD). While bathing the patient, the nurse senses that something is not quite right and takes
the patient's vital signs and obtains an oxygen saturation reading. The nurse is acting on which
of the following?
a. intuition
13. A community health nurse provides information to a patient with newly diagnosed multiple
sclerosis for a support group at the local hospital for patients diagnosed with multiple sclerosis
and their families. Providing this information is an example of which of the following?
a. A referral
14. A client presents to the clinic with reports of an itchy rash all over the body. The nurse observes
lesions on the client's arms and legs as well as the presence of a dry, hacky cough and sneezing.
Which data collected from the client can be classified as a subjective abnormal finding?
 a. Itchy feeling
15. A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the
best way to begin. The client states that he participates in routine exercise, but wants to increase
the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this
client based on this information?
a. Wellness diagnosis
16. A nurse provided dietary counsel for a client who recently immigrated to the United States from
Japan. During the initial interview, the client had his eyes lowered and did not make eye contact
with the nurse. In analysis of the data, the nurse wrote down the following hunch: “risk for
imbalanced nutrition related to client's unwillingness to listen to dietary advice.” At the next
meeting with the client a month later, however, the nurse was surprised to find that the client
had adopted all recommended changes from their initial interview. Which error did the nurse
commit in this case?
a. Overlooking consideration of the clients cultural background
17. The nurse is working with a 14-year-old girl who has told the nurse that she would like to try
getting to bed a little sooner to get a full night's sleep and have more energy at school. The
nurse diagnoses her with the following: Readiness for enhanced sleep related to client's
expressed desire to go to bed earlier. Which type of nursing diagnosis is this?
a. Wellness
18. The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous
(IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is
a different solution. What is the nurse's best action?
a. Review the client's prescribed medication orders.
19. Which assessment finding on a hospitalized adult client requires urgent intervention?
a. Urine output of 100 mL in 8 hours
20. The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse
recognizes this blood pressure is abnormally low for this client. What is best response of the
nurse?
a. Reassess blood pressure
21. The nurse has completed an assessment on a new patient. After gathering the data, formulating
a nursing diagnosis, and developing a plan of care, it is important for the nurse, before
finalizing the plan, to
a. discuss the plan with the patient
22. The nursing instructor informs the students that there are pitfalls that decrease the reliability of
cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of
data and includes which of the following?
a. too many or too few data
23. The nurse is formulating a nursing diagnosis for a patient that has had complete closure of an
open abdominal wound. What would be an appropriate nursing diagnosis for this patient?
a. Readiness for enhanced skin integrity
24. The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a
patient who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would
this be considered?
a. Actual Nursing Diagnosis
25. A patient who is 2 days postoperative reports pain and requests pain medication. After assessing
the patient's pain level, the nurse decides to give the patient oral oxycodone hydrochloride-
acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing
process?
a. implementation
26. A patient comes to the clinic for a yearly physical examination. The assessment reveals multiple
lesions on the face, neck, arms, and legs. The patient appears upset, starts to cry when
questioned about the skin abnormalities, and asks the nurse if the problem is skin cancer. What
would be the best nursing diagnosis for this patient?
a. Anxiety related to lesions on body
27. A client presents to the emergency department complaining of new onset chest pain. What is the
priority action of the nurse?
a. Place on cardiac monitor.
28. A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure
medication from home while he is hospitalized. The nurse reviews the orders and discovers that
indeed the client is not taking his usual blood pressure medication. Which preventive measure
was most likely omitted on admission?
a. Medication reconciliation
29. A nurse assesses an older adult client with confusion. When collecting clinical information from
the client, which factor is the most important for the nurse to consider?
a. The quality of the data may be low.
30. The nurse assesses a heart rate of 110 beats per minute (bpm), cool clammy skin, and blood
pressure 88/58 mm Hg. Which heading should the nurse use to cluster this data?
a. Low fluid volume
31. Essential characteristics for the development of critical thinking skills include all the following
except:
a. Following instructions
32. Which of the following events during the assessment process most indicates a need for
validation?
a. The client denies feeling upset or anxious about her recent cancer diagnosis but fidgets
throughout the interview and assessment.
33. Which of the following statements is true of nursing diagnoses?
a. They focus on the responses of clients to health problems and events.
34. The nurse realizes that after she confirms that the cluster data collected meet the characteristics
of a certain diagnosis, the next step is to do which of the following?
a. tell the patient what you perceive the diagnosis to be
35. When teaching the students about becoming effective diagnosticians, the nursing instructor
includes the following common errors made by novice nurses. (Select all the apply.)
a. See things as either right or wrong.
b. Focus only on the details.
36. A nurse is aware that when identifying abnormal data and strengths of the patient to make a
diagnosis, it is mandatory that the nurse considers which of the following?
a. risk factors
37. A hospital nurse is in the process of analyzing physical assessment data the nurse has collected
on a patient. Which characteristics of critical thinking should the nurse employ in the analysis?
Select all that apply.
a. Use rationale to support opinions and decisions.
b. Reflect on thoughts before reaching a conclusion.
c. Use past clinical experience to build knowledge.
38. What is pivotal to determining how to move from each client problem to its goals?
a. Clinical reasoning process
39. A common error for beginning nurses who are formulating nursing diagnoses during data
analysis is to
a. quickly make a diagnosis without hypothesizing several diagnoses.
40. The nurse notes that a client has a 2 cm x 5 cm area of redness over the left greater trochanter.
Which category should the nurse use when creating the nursing diagnosis for this finding?
a. Actual
41. The nurse collects data from a patient with a nonproductive cough and labored respirations at a
rate of 24/minute. What other data should the nurse collect before formulating an appropriate
nursing diagnosis?
a. status of breath sounds
42. The nursing student has learned that diagnostic reasoning has several pitfalls. The second set of
pitfalls usually occurs during the analysis phase and involves which of the following?
a. cues that are clustered yet unrelated
43. The nurse has clustered assessment data on a patient with cirrhosis of the liver that has altered
mental status due to the accumulation of ammonia toxins. What type of priority nursing
diagnosis would be indicated for this patient?
a. Actual nursing diagnosis.
44. The new graduate nurse asks the preceptor, "I keep hearing about learning to develop good
critical thinking skills, but don't really understand what that is?" What is the best response by
the preceptor?
a. "A way of processing information using to formulate conclusions or diagnoses."
45. A client reports sudden hair loss and a continuous itching sensation all over the body. The client
appears anxious and seems to be worried about her appearance. Which abnormal finding should
the nurse classify as objective data?
a. Anxious appearance
46. A nursing student is explaining to a roommate the relationship between diagnostic reasoning
and critical thinking. Which of the following is the correct statement for the nursing student to
make?
a. “Diagnostic reasoning is a form of critical thinking used to interpret data correctly.”
47. A hospitalized client reports pain 10/10 one hour after receiving a dose of intravenous morphine
sulfate. The next dose is not due for over an hour. What is the nurse's best action?
a. Notify the healthcare provider.
48. When formulating a nursing diagnosis, the format that is most useful to clearly document the
client’s problem is
a. NANDA label (for problem) + related to + etiology + AMB (as manifested by) + defining
characteristics.
49. The nurse is reviewing the laboratory report for a client with poorly controlled diabetes. This
action falls within which step of clinical reasoning?
a. identifying abnormal or positive findings
50. The nurse reviews data collected during an assessment. Which data should the nurse validate?
Select all that apply.
a. Data that is inconsistent with another finding
b. Subjective and objective data are inconsistent
c. Gap between what the client said and what is in the medical record
51. A client admitted to a health care facility for injuries received in a motor vehicle accident is
given the nursing diagnosis of Impaired Nutrition: Less than Body Requirements. What change
in the client's dietary requirements should the nurse anticipate?
a. Encourage intake of high density foods several times a day
52. A nurse understands that the identified strengths found during the assessment of a patient are
used for which of the following nursing diagnoses?
a. wellness diagnosis
53. The nursing student demonstrates understanding of the different types of patient problems when
he identifies which of the following to be a collaborative problem?
a. risk for complication: pneumothorax
54. A nursing student is learning how to use critical thinking in formulating a plan of care. The
student understands which of the following to be things needed to demonstrate that the process
of thinking critically has begun? (Select all that apply.)
a. reserves a final opinion until further collecting data
b. explores other alternatives before making a decision
c. uses past knowledge and experience to analyze data
55. A nurse is writing down hunches about certain cue clusters related to a client. Which of the
following hunches would seem to indicate the need to generate a collaborative problem as
opposed to a nursing diagnosis?
a. Inflamed appendix is causing severe abdominal pain.
56. After collecting subjective and objective data for the admission database, what is the nurse's
next action?
a. Validate the client's identified problems.
57. The nurse is walking by a client's room and notices the client's pulse oximeter reads 89% on the
monitor. What is the nurse's best action?
a. Enter the room and auscultate the client's lung sounds.
58. Which factor would assist the nurse in determining how to cluster clinical data into a single
problem for a 65-year-old male client with a chief report of lower back pain?
a. Timing
59. A nurse proposes a nursing diagnosis for a client based on subjective and objective data. What
step should the nurse perform before the diagnosis can be confirmed or ruled out?
a. Check for the presence of major and minor defining characteristics
60. In the diagnostic process, what should immediately precede the step of identifying a list of
possible nursing diagnoses?
a. Grouping assessment findings to identify commonalities
61. The nursing student learning about strengths and weaknesses of a patient understands that
which of the following is considered to be an example of abnormal objective data?
a. Anxious appearance
62. The nurse is formulating a nursing diagnosis for a patient that has developed a Stage III
decubitus ulcer on the sacrum. What would be an appropriate nursing diagnosis for this patient?
a. Alteration in skin integrity
63. Which of the following represents an accurate nursing diagnosis?
a. pain related to surgical incision
64. A nursing instructor is teaching about respiratory problems in the patient with chronic
obstructive pulmonary disease (COPD). The instructor realizes that the student needs more
teaching when the student states which of the following?
a. "Impaired gas exchange and ineffective breathing pattern can be interchanged."
65. A client admitted to a health care facility for injuries received in a motor vehicle accident is
given the nursing diagnosis of impaired nutrition: less than body requirement. Which type of
nursing diagnosis is this?
a. Actual
66. Which client-satisfaction related intervention of staff nurses may lead to improved client
outcomes?
a. Bedside hand-off reports
67. The RN notes the following assessment findings on a hospitalized older adult client admitted
with a diagnosis of acute confusion and urinary tract infection: BP 131/75, P 70, RR 18, temp
 97.2, oriented to person, place, time, and purpose; denial of urinary complaints. What is the
nurse's next action?
a. Ensure the call bell is within reach before leaving the room.
68. When caring for hospitalized clients, the nurse should recognize which potential safety hazards?
(Select all that apply.)
a. Call bell on bedside table
b. Multiple intravenous infusions
c. Urinary catheter under leg
d. Dim lighting