The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating correct answersAnswer: B
Rationale- The nurse identifies human responses to actual or potential h...
The nurse in charge identifies a patient's responses to actual or potential health problems during which
step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating correct answersAnswer: B
Rationale- The nurse identifies human responses to actual or potential health problems during the
nursing diagnoses step of the nursing process. During the assessment step, the nurse collects data.
During the planning step, the nurse develops strategies to resolve or decrease the patient's problem.
During evaluation, the nurse determines the effectiveness of the plan of care.
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the
highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion correct answersAnswer: D
Rationale: This answer takes highest priority because venous inflammation and clot formation impede
blood flow in a patient with deep-vein thrombosis.
Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow.
Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess.
Option C may be warranted but is secondary to altered tissue perfusion
, A nurse is revising a client's care plan. During which step of the nursing process does such a revision take
place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation correct answersAnswer: D
Rationale: During the evaluation step of the nursing process the nurse determines whether the goals
established have been achieved, and evaluates the success of the plan. Answer A involves data
collection. Answer B involves setting priorities, and Answer C is the actual intervention.
Which intervention should the nurse in charge try first for a client that exhibits signs of sleep
disturbance?
A. Administer sleeping medication before bedtime
B. Ask the client each morning to describe the quantity of sleep the night before
C. Teach the client relaxation techniques, such as guided imagery and progressive muscle relaxation
D. Provide the client normal sleep aids, such as pillows, back rubs, and snacks correct answersAnswer: D
Rationale: You should begin with the simplest interventions. Answer A is incorrect because medications
should be avoided whenever possible. Answer B would be a thorough sleep assessment, and should be
done only after common sense interventions fail. Answer C would be appropriate only after common
sense interventions fail.
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need?
A. Elimination
B. Security
C. Safety
D. Belonging correct answersAnswer- A
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