NUR2115 WRITTEN NURSING PROCESS
CASE COMPREHENSIVE STUDY GUIDE 2026
FULL QUESTIONS AND SOLUTIONS
GRADED A+
◍ Priority Problem.
Answer: The most significant issue identified during the assessment.
◍ Assessment.
Answer: Gather comprehensive data through physical examination, health
history, functional assessment, and review of laboratory and diagnostic
findings.
◍ In developing a plan of care for a client with chronic hypertension, which
nursing activity would be most important?
A. Set incremental goals for blood pressure reduction
B. Instruct the client to make dietary changes by reducing sodium intake
C. Include the client and family when setting goals and formulating the plan
of care
D. Assess past compliance to medication regimens.
Answer: C. Include the client and family when setting goals and formulating
the plan of careRationale: In developing a plan of care, nurses engage in a
partnership with the client and family. Nurses do not plan care for clients;
instead they plan care with clients and families. Assessment (option 4), goal
setting (option 1), and interventions (option 2) will be most accurate and
effective when carried out in partnership with the client and family. The
other options represent other actions to take, but they will have less overall
effectiveness if the client and family are not part of the plan.
◍ Etiology.
, Answer: Identifies factors maintaining the unhealthy state.
◍ Nursing Care Plan.
Answer: A plan that outlines the nursing interventions and expected
outcomes for a patient.
◍ Subjective Data.
Answer: Verbal statements from the patient or caregiver.
◍ Medium Priority.
Answer: Non-threatening diagnoses.
◍ In giving a change-of-shift report, which type of client information
communicated by the nurse is most appropriate?
A. Vital signs are stable
B. Client is pleasant, alert, and oriented to time, place, and person
C. The chest x-ray results were negative
D. Client voided 250 mL of urine 2 hours after the urinary catheter removal.
Answer: D. Client voided 250 mL of urine 2 hours after the urinary catheter
removalRationale: A change-of-shift report should include significant
changes (good or bad) in a client's condition. The information should be
accurate, concise, clear, and complete. Options 1 is vague and options 2 and
3 are normal data and are therefore of lesser importance to convey in the
change-of-shift report.
◍ Types of Assessment.
Answer: Primary survey, Admission Assessment, Ongoing Assessment,
Focused assessment.
◍ 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.
A. Hopelessness
B. Powerlessness
C. Interrupted sleep pattern
, D. Disturbed self esteem
E. Self care deficit.
Answer: A. HopelessnessB. PowerlessnessRationale: 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).
◍ Types of Assessments.
Answer: Medical and Nursing assessments.
◍ Medical Diagnosis.
Answer: Describes problems for which the physician directs the primary
treatment.
◍ Which activity would be appropriate for the nurse to delegate to an
unlicensed assistive person (UAP)?
A. Taking vital signs of clients on the nursing unit
B. Assisting the physician with an invasive procedure
C. Adjusting the rate on an infusion pump
D. Evaluating achievement of client outcome goals.
Answer: A. Taking vital signs of clients on the nursing unitRationale: Part of
the professional nurse's role is to delegate responsibility for activities while
maintaining accountability. The nurse must match the needs of the client
with the skills and knowledge of UAPs. Certain skills and activities, such as
those in options 2, 3, and 4, are not within the legal scope of practice for a
UAP.
◍ Twenty minutes after administering pain medication to the client, the nurse
returns to ask if the client's level of pain has decreased. The nurse
documents the client's response as part of which phase of the nursing
process?
A. Diagnosis
CASE COMPREHENSIVE STUDY GUIDE 2026
FULL QUESTIONS AND SOLUTIONS
GRADED A+
◍ Priority Problem.
Answer: The most significant issue identified during the assessment.
◍ Assessment.
Answer: Gather comprehensive data through physical examination, health
history, functional assessment, and review of laboratory and diagnostic
findings.
◍ In developing a plan of care for a client with chronic hypertension, which
nursing activity would be most important?
A. Set incremental goals for blood pressure reduction
B. Instruct the client to make dietary changes by reducing sodium intake
C. Include the client and family when setting goals and formulating the plan
of care
D. Assess past compliance to medication regimens.
Answer: C. Include the client and family when setting goals and formulating
the plan of careRationale: In developing a plan of care, nurses engage in a
partnership with the client and family. Nurses do not plan care for clients;
instead they plan care with clients and families. Assessment (option 4), goal
setting (option 1), and interventions (option 2) will be most accurate and
effective when carried out in partnership with the client and family. The
other options represent other actions to take, but they will have less overall
effectiveness if the client and family are not part of the plan.
◍ Etiology.
, Answer: Identifies factors maintaining the unhealthy state.
◍ Nursing Care Plan.
Answer: A plan that outlines the nursing interventions and expected
outcomes for a patient.
◍ Subjective Data.
Answer: Verbal statements from the patient or caregiver.
◍ Medium Priority.
Answer: Non-threatening diagnoses.
◍ In giving a change-of-shift report, which type of client information
communicated by the nurse is most appropriate?
A. Vital signs are stable
B. Client is pleasant, alert, and oriented to time, place, and person
C. The chest x-ray results were negative
D. Client voided 250 mL of urine 2 hours after the urinary catheter removal.
Answer: D. Client voided 250 mL of urine 2 hours after the urinary catheter
removalRationale: A change-of-shift report should include significant
changes (good or bad) in a client's condition. The information should be
accurate, concise, clear, and complete. Options 1 is vague and options 2 and
3 are normal data and are therefore of lesser importance to convey in the
change-of-shift report.
◍ Types of Assessment.
Answer: Primary survey, Admission Assessment, Ongoing Assessment,
Focused assessment.
◍ 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.
A. Hopelessness
B. Powerlessness
C. Interrupted sleep pattern
, D. Disturbed self esteem
E. Self care deficit.
Answer: A. HopelessnessB. PowerlessnessRationale: 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).
◍ Types of Assessments.
Answer: Medical and Nursing assessments.
◍ Medical Diagnosis.
Answer: Describes problems for which the physician directs the primary
treatment.
◍ Which activity would be appropriate for the nurse to delegate to an
unlicensed assistive person (UAP)?
A. Taking vital signs of clients on the nursing unit
B. Assisting the physician with an invasive procedure
C. Adjusting the rate on an infusion pump
D. Evaluating achievement of client outcome goals.
Answer: A. Taking vital signs of clients on the nursing unitRationale: Part of
the professional nurse's role is to delegate responsibility for activities while
maintaining accountability. The nurse must match the needs of the client
with the skills and knowledge of UAPs. Certain skills and activities, such as
those in options 2, 3, and 4, are not within the legal scope of practice for a
UAP.
◍ Twenty minutes after administering pain medication to the client, the nurse
returns to ask if the client's level of pain has decreased. The nurse
documents the client's response as part of which phase of the nursing
process?
A. Diagnosis
