ESTUDYR
NURS104 FINAL 2025 EXAM UPDATE WITH
COMPLETE QUESTIONS AND ANSWERS
A nurse will arrive at a nursing diagnosis through which step of the nursing process?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Rationale: Assessment is the data-collection phase that yields information used to formulate
nursing diagnoses.
A student nurse can begin developing critical thinking skills by:
A. Memorizing procedures only
B. Repeating tasks without reflection
C. Listening attentively and focusing on the speaker's words and meaning
D. Avoiding feedback
Rationale: Active listening fosters comprehension, reflection, and the beginnings of critical
thinking.
In triage an ER nurse gives first priority to the patient with the most critical need. Which
patient should be seen first?
A. Mild earache
B. Sprained ankle
C. Complaints of severe chest pain
D. Persistent cough for 2 days
Rationale: Chest pain may indicate life-threatening cardiac ischemia requiring immediate
attention.
Constant nursing assessments and evaluations most likely result in:
A. Static care plans
B. Delayed interventions
C. Patient discharge only
D. Nursing care plan changes to reflect appropriate priorities
Rationale: Ongoing assessment ensures the plan is updated as patient status changes.
Which activities are part of the nursing diagnosis step? (Select all that apply.)
A. Implementing interventions
B. Determination of potential health problems
C. Clustering of related assessments
D. Writing physician orders
Rationale: Nursing diagnosis involves analyzing assessment data and clustering cues to identify
problems.
In the collaborative delivery of care, an LPN/LVN’s responsibility often is to:
A. Prescribe medications
B. Diagnose conditions
,ESTUDYR
C. Perform comprehensive assessments independently
D. Collect data of health status
Rationale: LPNs often gather data and report findings for RN assessment and planning.
Once a nursing plan is initiated, the nursing care plan will:
A. Remain unchanged
B. Be discarded after 24 hours
C. Only change if the physician orders it
D. Change as the patient's condition changes
Rationale: Care plans are dynamic and must be revised with changing patient needs.
Which activity is an example of implementation in nursing care?
A. Writing a diagnosis
B. Creating discharge plans
C. Evaluating outcomes
D. Changing the patient's surgical dressing
Rationale: Implementation involves carrying out interventions such as wound care.
Using a scientific problem-solving approach in nursing decision making will:
A. Make care less structured
B. Increase guesswork
C. Reduce accountability
D. Improve nursing care outcomes
Rationale: Systematic problem solving promotes effective, evidence-based decisions.
The nurse who uses the nursing process will:
A. Skip assessment and act immediately
B. Use only intuition
C. Act without reflection
D. Approach the patient's disorder in a step-by-step method
Rationale: The nursing process provides sequential steps for patient care.
What is the correct order of the nursing process?
A. Diagnosis, assessment, planning, implementation, evaluation
B. Assessment, planning, diagnosis, implementation, evaluation
C. Planning, assessment, diagnosis, implementation, evaluation
D. Assessment, nursing diagnosis, planning, implementation, evaluation
Rationale: Standard sequence begins with assessment, then diagnosis, planning,
implementation, evaluation.
Participants in the planning stage who help define health goals include:
A. Only the physician
B. Only the RN
C. Only the insurance company
D. The health team, the patient, and the patient's family
Rationale: Planning is collaborative and should involve patient/family input.
When prioritizing patient care, consideration should be given to:
A. Personal preferences only
B. Physician convenience
C. Room aesthetics
, ESTUDYR
D. Situations that may result in an alteration of health
Rationale: Priorities focus on safety and risks to the patient’s health.
When a patient says, “I can't walk very well,” the first problem-solving step is to:
A. Prescribe PT automatically
B. Ignore the statement
C. Tell them to try harder
D. Find out specifically what the problem is (e.g., weakness or poor balance)
Rationale: Clarifying the problem guides appropriate assessment and intervention.
A nurse performs a digital rectal exam and finds a hard fecal mass in a resident reporting
constipation. This action is an example of:
A. Planning
B. Intervention only
C. Evaluation only
D. Assessment
Rationale: Physical examination is part of data collection/assessment.
Checking a patient 45 minutes after giving pain medication to see if pain is relieved is:
A. Planning
B. Assessment only
C. Documentation exclusively
D. Evaluation
Rationale: Evaluation measures the patient’s response to the intervention.
A nursing care plan consists of:
A. Physician orders only
B. Insurance goals only
C. Standardized hospital policies only
D. Nursing orders for individualized interventions to assist the patient to meet expected
outcomes
Rationale: Care plans direct individualized nursing interventions aimed at outcomes.
A nursing diagnosis consists of:
A. Medical disease names only
B. Diagnostic tests to be ordered
C. Medication lists
D. Diagnostic labels (NANDA-I) describing patient responses
Rationale: NANDA-I provides standardized nursing diagnostic labels for patient responses.
A visually impaired patient at risk for falls related to blindness — an appropriate nursing
intervention would be to:
A. Leave the environment unchanged
B. Wheel the patient around randomly
C. Encourage the patient to navigate unassisted
D. Arrange furnishings to provide clear pathways and orient the patient to those paths
Rationale: Environmental modifications and orientation reduce fall risk for visual impairment.
An appropriately worded nursing diagnosis for a patient with COPD, cough, dyspnea, and
thick secretions is:
A. Fluid volume excess related to cough
NURS104 FINAL 2025 EXAM UPDATE WITH
COMPLETE QUESTIONS AND ANSWERS
A nurse will arrive at a nursing diagnosis through which step of the nursing process?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Rationale: Assessment is the data-collection phase that yields information used to formulate
nursing diagnoses.
A student nurse can begin developing critical thinking skills by:
A. Memorizing procedures only
B. Repeating tasks without reflection
C. Listening attentively and focusing on the speaker's words and meaning
D. Avoiding feedback
Rationale: Active listening fosters comprehension, reflection, and the beginnings of critical
thinking.
In triage an ER nurse gives first priority to the patient with the most critical need. Which
patient should be seen first?
A. Mild earache
B. Sprained ankle
C. Complaints of severe chest pain
D. Persistent cough for 2 days
Rationale: Chest pain may indicate life-threatening cardiac ischemia requiring immediate
attention.
Constant nursing assessments and evaluations most likely result in:
A. Static care plans
B. Delayed interventions
C. Patient discharge only
D. Nursing care plan changes to reflect appropriate priorities
Rationale: Ongoing assessment ensures the plan is updated as patient status changes.
Which activities are part of the nursing diagnosis step? (Select all that apply.)
A. Implementing interventions
B. Determination of potential health problems
C. Clustering of related assessments
D. Writing physician orders
Rationale: Nursing diagnosis involves analyzing assessment data and clustering cues to identify
problems.
In the collaborative delivery of care, an LPN/LVN’s responsibility often is to:
A. Prescribe medications
B. Diagnose conditions
,ESTUDYR
C. Perform comprehensive assessments independently
D. Collect data of health status
Rationale: LPNs often gather data and report findings for RN assessment and planning.
Once a nursing plan is initiated, the nursing care plan will:
A. Remain unchanged
B. Be discarded after 24 hours
C. Only change if the physician orders it
D. Change as the patient's condition changes
Rationale: Care plans are dynamic and must be revised with changing patient needs.
Which activity is an example of implementation in nursing care?
A. Writing a diagnosis
B. Creating discharge plans
C. Evaluating outcomes
D. Changing the patient's surgical dressing
Rationale: Implementation involves carrying out interventions such as wound care.
Using a scientific problem-solving approach in nursing decision making will:
A. Make care less structured
B. Increase guesswork
C. Reduce accountability
D. Improve nursing care outcomes
Rationale: Systematic problem solving promotes effective, evidence-based decisions.
The nurse who uses the nursing process will:
A. Skip assessment and act immediately
B. Use only intuition
C. Act without reflection
D. Approach the patient's disorder in a step-by-step method
Rationale: The nursing process provides sequential steps for patient care.
What is the correct order of the nursing process?
A. Diagnosis, assessment, planning, implementation, evaluation
B. Assessment, planning, diagnosis, implementation, evaluation
C. Planning, assessment, diagnosis, implementation, evaluation
D. Assessment, nursing diagnosis, planning, implementation, evaluation
Rationale: Standard sequence begins with assessment, then diagnosis, planning,
implementation, evaluation.
Participants in the planning stage who help define health goals include:
A. Only the physician
B. Only the RN
C. Only the insurance company
D. The health team, the patient, and the patient's family
Rationale: Planning is collaborative and should involve patient/family input.
When prioritizing patient care, consideration should be given to:
A. Personal preferences only
B. Physician convenience
C. Room aesthetics
, ESTUDYR
D. Situations that may result in an alteration of health
Rationale: Priorities focus on safety and risks to the patient’s health.
When a patient says, “I can't walk very well,” the first problem-solving step is to:
A. Prescribe PT automatically
B. Ignore the statement
C. Tell them to try harder
D. Find out specifically what the problem is (e.g., weakness or poor balance)
Rationale: Clarifying the problem guides appropriate assessment and intervention.
A nurse performs a digital rectal exam and finds a hard fecal mass in a resident reporting
constipation. This action is an example of:
A. Planning
B. Intervention only
C. Evaluation only
D. Assessment
Rationale: Physical examination is part of data collection/assessment.
Checking a patient 45 minutes after giving pain medication to see if pain is relieved is:
A. Planning
B. Assessment only
C. Documentation exclusively
D. Evaluation
Rationale: Evaluation measures the patient’s response to the intervention.
A nursing care plan consists of:
A. Physician orders only
B. Insurance goals only
C. Standardized hospital policies only
D. Nursing orders for individualized interventions to assist the patient to meet expected
outcomes
Rationale: Care plans direct individualized nursing interventions aimed at outcomes.
A nursing diagnosis consists of:
A. Medical disease names only
B. Diagnostic tests to be ordered
C. Medication lists
D. Diagnostic labels (NANDA-I) describing patient responses
Rationale: NANDA-I provides standardized nursing diagnostic labels for patient responses.
A visually impaired patient at risk for falls related to blindness — an appropriate nursing
intervention would be to:
A. Leave the environment unchanged
B. Wheel the patient around randomly
C. Encourage the patient to navigate unassisted
D. Arrange furnishings to provide clear pathways and orient the patient to those paths
Rationale: Environmental modifications and orientation reduce fall risk for visual impairment.
An appropriately worded nursing diagnosis for a patient with COPD, cough, dyspnea, and
thick secretions is:
A. Fluid volume excess related to cough
