NR226 HESI Exam Questions and Correct
Answers Already Graded A+ 2025
A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination.
The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment
uses which of the following approaches while conducting the interview with this patient? (Select all
that apply.)
A. Maintain a neutral facial expression
B. Lean forward when interacting with the patient
C. Acknowledge the patient's answers through head nodding
D. Limit direct eye contact
B&C
-Leaning forward shows that the nurse is aware and attending to what the patient is saying. The use
of head nodding regulates the interaction and makes it easier for the patient to know the nurse's
responses to his comments. A neutral expression does not express warmth or immediacy, which is
needed to establish a positive relationship. Good eye contact communicates the nurse's interest in
what the patient has to say.
Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select
all that apply.)
A. Anxiety related to fear of dying
B. Fatigue related to chronic emphysema
C. Need for mouth care related to inflamed mucosa
D. Risk for infection
A&D
-The diagnosis "Anxiety related to fear of dying" is stated correctly, with the related factor being the
patient's response to a health problem. Risk for infection is a risk factor for an at-risk diagnosis. In all
cases the related factor or risk factor is a condition for which the nurse can implement preventive
measures. Fatigue related to chronic emphysema is incorrect since chronic emphysema is a medical
diagnosis. Need for mouth care related to inflamed mucosa is not a NANDA-I-approved nursing
diagnosis.
A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the
defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as
the correct diagnosis. This is an example of the nurse avoiding an error in:
A. Data collection.
B. Data clustering.
C. Data interpretation.
D. Making a diagnostic statement.
C. Data interpretation
,-In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and
selects one based on the interpretation of data. Making a diagnostic statement is incorrect because
the nurse has not included a related factor.
The nursing diagnosis readiness for enhanced communication is an example of a(n):
A. Risk nursing diagnosis.
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,B. Actual nursing diagnosis.
C. Health promotion nursing diagnosis
D. Wellness nursing diagnosis.
C. Health promotion nursing diagnosis
-A patient's readiness for enhanced communication is an example of a health-promotion diagnosis
because it implies the patient's motivation and desire to strengthen his health.
In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.)
A. The nurse who listens to lung sounds after a patient reports "difficulty breathing"
B. The nurse who considers conflicting cues in deciding which diagnostic label to choose
C. The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of
edema
D. The nurse who identifies a diagnosis on the basis of a single defining characteristic
C&D
-When the nurse assesses edema without knowing how to assess the severity, the nurse fails to
validate her assessment findings of edema, either by using a scale to measure the severity or by
asking a colleague to validate her findings. In identifying a diagnosis on the basis of a single defining
characteristic, the nurse prematurely closes clustering, which can lead to an inaccurate diagnosis. By
listening to lung sounds after the patient reports "difficulty breathing" the nurse validates findings
to make an accurate diagnosis. The nurse interprets cue clusters to make an accurate diagnosis when
considering conflicting cues to make a diagnosis.
A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent
nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic
statement, best described as:
A. Identifying the clinical sign instead of an etiology.
B. Identifying a diagnosis based on prejudicial judgment.
C. Identifying the diagnostic study rather than a problem caused by the diagnostic study.
D. Identifying the medical diagnosis instead of the patient's response to the diagnosis.
D. Identifying the medical diagnosis instead of the patient's response to the diagnosis
-In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.
Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that
apply.)
A. Acute pain related to lumbar disk repair
B. Sleep deprivation related to difficulty falling asleep
C. Constipation related to inadequate intake of liquids
D. Potential nausea related to nasogastric tube insertion
A, B & D
-Acute pain related to lumbar disk repair uses a medical diagnosis as a related factor. Sleep
deprivation related to difficulty falling asleep uses a clinical sign rather than a treatable etiology such
as "excess noise in environment." Potential nausea related to nasogastric tube insertion uses a
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, diagnostic study as the etiology. None of the etiologies can be managed or treated by nursing
intervention.
Which of the following are examples of collaborative problems? (Select all that apply.)
A. Nausea
B. Hemorrhage
C. Wound infection
D. Fear
B&C
-Hemorrhage and wound infection are collaborative problems, actual or potential physiological
complications. Nurses typically monitor for these to detect changes in a patient's status. Nausea and
fear are both NANDA-I approved nursing diagnoses.
.!
Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added,
"Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's
colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over
it together." A correctly worded diagnostic statement is:
A. Need for improved bowel function related to change in diet.
B. Patient needs improved bowel function related to alteration in elimination.
C. Constipation related to inadequate fluid intake.
D. Constipation related to hard infrequent stools.
C. Constipation related to inadequate fluid intake
-Constipation related to inadequate fluid intake is an accurate NANDA-I approved nursing diagnosis
with an appropriate etiology. Need for improved bowel function related to change in diet is a goal
with an etiologic factor. Patient needs improved bowel function related to alteration in elimination is
a goal with a diagnostic statement. Constipation related to hard infrequent stools is a nursing
diagnostic label with a clinical sign.
The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the
care plan, which diagnoses will not include defining characteristics?
A. Risk for aspiration
B. Acute confusion
C. Readiness for enhanced coping
D. Sedentary lifestyle
A. Risk for aspiration
-A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the
environmental, physiological, psychological, genetic, or chemical elements that place a person at risk
for a health problem.
A+ TEST BANK 7
Answers Already Graded A+ 2025
A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination.
The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment
uses which of the following approaches while conducting the interview with this patient? (Select all
that apply.)
A. Maintain a neutral facial expression
B. Lean forward when interacting with the patient
C. Acknowledge the patient's answers through head nodding
D. Limit direct eye contact
B&C
-Leaning forward shows that the nurse is aware and attending to what the patient is saying. The use
of head nodding regulates the interaction and makes it easier for the patient to know the nurse's
responses to his comments. A neutral expression does not express warmth or immediacy, which is
needed to establish a positive relationship. Good eye contact communicates the nurse's interest in
what the patient has to say.
Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select
all that apply.)
A. Anxiety related to fear of dying
B. Fatigue related to chronic emphysema
C. Need for mouth care related to inflamed mucosa
D. Risk for infection
A&D
-The diagnosis "Anxiety related to fear of dying" is stated correctly, with the related factor being the
patient's response to a health problem. Risk for infection is a risk factor for an at-risk diagnosis. In all
cases the related factor or risk factor is a condition for which the nurse can implement preventive
measures. Fatigue related to chronic emphysema is incorrect since chronic emphysema is a medical
diagnosis. Need for mouth care related to inflamed mucosa is not a NANDA-I-approved nursing
diagnosis.
A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the
defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as
the correct diagnosis. This is an example of the nurse avoiding an error in:
A. Data collection.
B. Data clustering.
C. Data interpretation.
D. Making a diagnostic statement.
C. Data interpretation
,-In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and
selects one based on the interpretation of data. Making a diagnostic statement is incorrect because
the nurse has not included a related factor.
The nursing diagnosis readiness for enhanced communication is an example of a(n):
A. Risk nursing diagnosis.
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,B. Actual nursing diagnosis.
C. Health promotion nursing diagnosis
D. Wellness nursing diagnosis.
C. Health promotion nursing diagnosis
-A patient's readiness for enhanced communication is an example of a health-promotion diagnosis
because it implies the patient's motivation and desire to strengthen his health.
In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.)
A. The nurse who listens to lung sounds after a patient reports "difficulty breathing"
B. The nurse who considers conflicting cues in deciding which diagnostic label to choose
C. The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of
edema
D. The nurse who identifies a diagnosis on the basis of a single defining characteristic
C&D
-When the nurse assesses edema without knowing how to assess the severity, the nurse fails to
validate her assessment findings of edema, either by using a scale to measure the severity or by
asking a colleague to validate her findings. In identifying a diagnosis on the basis of a single defining
characteristic, the nurse prematurely closes clustering, which can lead to an inaccurate diagnosis. By
listening to lung sounds after the patient reports "difficulty breathing" the nurse validates findings
to make an accurate diagnosis. The nurse interprets cue clusters to make an accurate diagnosis when
considering conflicting cues to make a diagnosis.
A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent
nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic
statement, best described as:
A. Identifying the clinical sign instead of an etiology.
B. Identifying a diagnosis based on prejudicial judgment.
C. Identifying the diagnostic study rather than a problem caused by the diagnostic study.
D. Identifying the medical diagnosis instead of the patient's response to the diagnosis.
D. Identifying the medical diagnosis instead of the patient's response to the diagnosis
-In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.
Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that
apply.)
A. Acute pain related to lumbar disk repair
B. Sleep deprivation related to difficulty falling asleep
C. Constipation related to inadequate intake of liquids
D. Potential nausea related to nasogastric tube insertion
A, B & D
-Acute pain related to lumbar disk repair uses a medical diagnosis as a related factor. Sleep
deprivation related to difficulty falling asleep uses a clinical sign rather than a treatable etiology such
as "excess noise in environment." Potential nausea related to nasogastric tube insertion uses a
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, diagnostic study as the etiology. None of the etiologies can be managed or treated by nursing
intervention.
Which of the following are examples of collaborative problems? (Select all that apply.)
A. Nausea
B. Hemorrhage
C. Wound infection
D. Fear
B&C
-Hemorrhage and wound infection are collaborative problems, actual or potential physiological
complications. Nurses typically monitor for these to detect changes in a patient's status. Nausea and
fear are both NANDA-I approved nursing diagnoses.
.!
Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added,
"Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's
colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over
it together." A correctly worded diagnostic statement is:
A. Need for improved bowel function related to change in diet.
B. Patient needs improved bowel function related to alteration in elimination.
C. Constipation related to inadequate fluid intake.
D. Constipation related to hard infrequent stools.
C. Constipation related to inadequate fluid intake
-Constipation related to inadequate fluid intake is an accurate NANDA-I approved nursing diagnosis
with an appropriate etiology. Need for improved bowel function related to change in diet is a goal
with an etiologic factor. Patient needs improved bowel function related to alteration in elimination is
a goal with a diagnostic statement. Constipation related to hard infrequent stools is a nursing
diagnostic label with a clinical sign.
The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the
care plan, which diagnoses will not include defining characteristics?
A. Risk for aspiration
B. Acute confusion
C. Readiness for enhanced coping
D. Sedentary lifestyle
A. Risk for aspiration
-A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the
environmental, physiological, psychological, genetic, or chemical elements that place a person at risk
for a health problem.
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