BSN 266 NURSING PROCESS
DOCUMENTATION AND CARE PLANNING
FINAL PAPER WORKBOOK 2026
◉ Small bowel obstruction is a condition characterized by which
finding?
A. Severe fluid and electrolyte imbalances.
B. Metabolic acidosis.
C. Ribbon-like stools.
D. Intermittent lower abdominal cramping.
Answer: A. Severe fluid and electrolyte imbalances.
Rationale
Among the findings characteristic of a small bowel obstruction is the
presence of severe fluid and electrolyte imbalances.
◉ The nurse is assessing a client with chronic kidney disease (CKD).
Which finding is most important for the nurse to respond to first?
A. Potassium 6.0 mEq.
B. Daily urine output of 400 ml.
C. Peripheral neuropathy.
D. Uremic fetor.
Answer: A. Potassium 6.0 mEq.
,Rationale
Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious
electrolyte disorder that can cause fatal arrhythmias, so the
elevation of the potassium level is a nursing priority.
◉ A middle-aged male client with diabetes continues to eat an
abundance of foods that are high in sugar and fat. According to the
Health Belief Model, which event is most likely to increase the
client's willingness to become compliant with the prescribed diet?
A. He visits his diabetic brother who just had surgery to amputate an
infected foot.
B. He is provided with the most current information about the
dangers of untreated diabetes.
C. He comments on the community service announcements about
preventing complications associated with diabetes.
D. His wife expresses a sincere willingness to prepare meals that are
within his prescribed diet.
Answer: A. He visits his diabetic brother who just had surgery to
amputate an infected foot.
Rationale
The loss of a limb due to diabetes by a family member should be the
strongest event or "cue to action" and is most likely to increase the
client's perceived seriousness of the disease.
,◉ A female client requests information about using the calendar
method of contraception. Which assessment is most important for
the nurse to obtain?
A. Amount of weight gain or weight loss during the previous year.
B. An accurate menstrual cycle diary for the past 6 to 12 months.
C. Skin pigmentation and hair texture for evidence of hormonal
changes.
D. Previous birth-control methods and beliefs about the calendar
method.
Answer: B. An accurate menstrual cycle diary for the past 6 to 12
months.
Rationale
The fertile period, which occurs 2 weeks prior to the onset of
menses, is determined using an accurate record of the number of
days of the menstrual cycles for the past 6 months, so it is most
important to emphasize to the client that accuracy and being
compliant in recording the menstrual diary is the basis of the
calendar method.
◉ The nurse assesses a client with advanced cirrhosis of the liver for
signs of hepatic encephalopathy. Which finding would the nurse
consider an indication of progressive hepatic encephalopathy?
A. An increase in abdominal girth.
B. Hypertension and a bounding pulse.
C. Decreased bowel sounds.
, D. Difficulty in handwriting.
Answer: D. Difficulty in handwriting.
Rationale
A daily record in handwriting may provide evidence of progression
or reversal of hepatic encephalopathy leading to coma (D). (A) is a
sign of ascites. (B) are not seen with hepatic encephalopathy. (C)
does not indicate an increase in serum ammonia level which is the
primary cause of hepatic encephalopathy.
◉ During lung assessment, the nurse places a stethoscope on a
client's chest and instructs him/her to say "99" each time the chest
is touched with the stethoscope. What would be the correct
interpretation if the nurse hears the spoken words "99" very clearly
through the stethoscope?
A. This is a normal auscultatory finding.
B. May indicate pneumothorax.
C. May indicate pneumonia.
D. May indicate severe emphysema.
Answer: C. May indicate pneumonia.
Rationale
This test (whispered pectoriloquy) demonstrates hyperresonance
and helps determine the clarity with which spoken words are heard
upon auscultation. Normally, the spoken word is not well
transmitted through lung tissue, and is heard as a muffled or unclear
transmission of the spoken word. Increased clarity of a spoken word
DOCUMENTATION AND CARE PLANNING
FINAL PAPER WORKBOOK 2026
◉ Small bowel obstruction is a condition characterized by which
finding?
A. Severe fluid and electrolyte imbalances.
B. Metabolic acidosis.
C. Ribbon-like stools.
D. Intermittent lower abdominal cramping.
Answer: A. Severe fluid and electrolyte imbalances.
Rationale
Among the findings characteristic of a small bowel obstruction is the
presence of severe fluid and electrolyte imbalances.
◉ The nurse is assessing a client with chronic kidney disease (CKD).
Which finding is most important for the nurse to respond to first?
A. Potassium 6.0 mEq.
B. Daily urine output of 400 ml.
C. Peripheral neuropathy.
D. Uremic fetor.
Answer: A. Potassium 6.0 mEq.
,Rationale
Hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious
electrolyte disorder that can cause fatal arrhythmias, so the
elevation of the potassium level is a nursing priority.
◉ A middle-aged male client with diabetes continues to eat an
abundance of foods that are high in sugar and fat. According to the
Health Belief Model, which event is most likely to increase the
client's willingness to become compliant with the prescribed diet?
A. He visits his diabetic brother who just had surgery to amputate an
infected foot.
B. He is provided with the most current information about the
dangers of untreated diabetes.
C. He comments on the community service announcements about
preventing complications associated with diabetes.
D. His wife expresses a sincere willingness to prepare meals that are
within his prescribed diet.
Answer: A. He visits his diabetic brother who just had surgery to
amputate an infected foot.
Rationale
The loss of a limb due to diabetes by a family member should be the
strongest event or "cue to action" and is most likely to increase the
client's perceived seriousness of the disease.
,◉ A female client requests information about using the calendar
method of contraception. Which assessment is most important for
the nurse to obtain?
A. Amount of weight gain or weight loss during the previous year.
B. An accurate menstrual cycle diary for the past 6 to 12 months.
C. Skin pigmentation and hair texture for evidence of hormonal
changes.
D. Previous birth-control methods and beliefs about the calendar
method.
Answer: B. An accurate menstrual cycle diary for the past 6 to 12
months.
Rationale
The fertile period, which occurs 2 weeks prior to the onset of
menses, is determined using an accurate record of the number of
days of the menstrual cycles for the past 6 months, so it is most
important to emphasize to the client that accuracy and being
compliant in recording the menstrual diary is the basis of the
calendar method.
◉ The nurse assesses a client with advanced cirrhosis of the liver for
signs of hepatic encephalopathy. Which finding would the nurse
consider an indication of progressive hepatic encephalopathy?
A. An increase in abdominal girth.
B. Hypertension and a bounding pulse.
C. Decreased bowel sounds.
, D. Difficulty in handwriting.
Answer: D. Difficulty in handwriting.
Rationale
A daily record in handwriting may provide evidence of progression
or reversal of hepatic encephalopathy leading to coma (D). (A) is a
sign of ascites. (B) are not seen with hepatic encephalopathy. (C)
does not indicate an increase in serum ammonia level which is the
primary cause of hepatic encephalopathy.
◉ During lung assessment, the nurse places a stethoscope on a
client's chest and instructs him/her to say "99" each time the chest
is touched with the stethoscope. What would be the correct
interpretation if the nurse hears the spoken words "99" very clearly
through the stethoscope?
A. This is a normal auscultatory finding.
B. May indicate pneumothorax.
C. May indicate pneumonia.
D. May indicate severe emphysema.
Answer: C. May indicate pneumonia.
Rationale
This test (whispered pectoriloquy) demonstrates hyperresonance
and helps determine the clarity with which spoken words are heard
upon auscultation. Normally, the spoken word is not well
transmitted through lung tissue, and is heard as a muffled or unclear
transmission of the spoken word. Increased clarity of a spoken word
