Fundamentals of Nursing, Nursing
Process 2025
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While
taking the client's vital signs, the nurse is implementing which phase of the nursing
process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - Answers>>A. Assessment
Rationale: The first step in the nursing process is assessment, the process of collecting
data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on
accurate and complete data.
A client on the nursing unit is terminally ill but remains alert and oriented. Three days
after admission, the nurse observes signs of depression. The client states, "I'm tired of
being sick. I wish I could end it all." What is the most accurate and informative way to
record this data in a nursing progress note?
A. Client appears to be depressed, possibly suicidal
B. Client reports being tired of being ill and wants to die
C. Client does not want to live any longer and is tired of being ill
D. Client states, "I'm tired of being sick. I wish I could end it all." - Answers>>D. Client
states, "I'm tired of being sick. I wish I could end it all."
Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and
sensations that are apparent only to the person affected and cannot be measured,
seen, or felt by the nurse. This information should be documented using the client's
exact words in quotes. The other options indicate that the nurse has drawn the
conclusion that the client no longer wishes to live. From the data provided, the cues do
not support this assumption. A more complete assessment should be conducted to
determine if the client is suicidal.
A client who complains of nausea and seems anxious is admitted to the nursing unit.
The nurse should take which of the following actions regarding completion of the
admission interview?
A. Help the client to get settled and do the interview the next morning when the client is
rested
B. Do the interview immediately, directing the majority of the questions to the client's
spouse
C. Do the interview as soon as some uninterrupted time is available in order to address
the client's concerns
,D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor
for anti-nausea and anti-anxiety medication - Answers>>C. Do the interview as soon as
some uninterrupted time is available in order to address the client's concerns
Rationale: To collect data accurately, the client must participate. Attending to the client's
immediate personal needs before expecting the client to focus on the interview will
maximize the accuracy of the data collected. Data should be collected shortly after
admission. The best source of data is the client. The management of the client's anxiety
is the responsibility of the nurse conducting the interview and initiating the relationship.
A desired outcome for a client immobilized in a long leg cast reads; Client will state
three signs of impaired circulation prior to discharge. When the nurse evaluates the
client's progress, the client is able to state that numbness and tingling are signs of
impaired circulation. What would be an appropriate evaluation statement for the nurse
to write?
A. Client understands the signs of impaired circulation
B. Goal met: Client cited numbness and tingling as sign of impaired circulation
C. Goal not met: Client able to name only two signs of impaired circulation
D. Goal not met: Client unable to describe signs of impaired circulation - Answers>>C.
Goal not met: Client able to name only two signs of impaired circulation
Rationale: The goal has not been met because the client states only two out of three
signs of impaired circulation. By comparing the data with the expected outcomes, the
nurse judges that while there has been progress toward the goal, it has not been
completely met. The care plan may need to be revised or more effective teaching
strategies may need to be implemented to achieve the goal.
A nurse explains to a student that the nursing process is a dynamic process. Which of
the following actions by the nurse best demonstrates this concept during the work shift?
A. Nurse and client agree upon health care goals for the client
B. Nurse reviews the client's history on the medical record
C. Nurse explains to the client the purpose of each administered medication
D. Nurse rapidly reset priorities for client care based on a change in the client's
condition - Answers>>D. Nurse rapidly reset priorities for client care based on a change
in the client's condition
Rationale: The nursing process is characterized by unique properties that enable it to
respond to the changing health status of the client. Options 1, 2, and 3 are appropriate
nursing care measures, but do not demonstrate the dynamic nature of the nursing
process.
After instructing the client on crutch walking technique, the nurse should evaluate the
client's understanding by using which of the following methods?
, A. Return demonstration
B. Explanation
C. Achievement of 90 on written test
D. Have client explain produce to the family - Answers>>A. Return demonstration
Rationale: Interpersonal skills are the sum of the activities the nurse uses when
communicating with others. Technical/psychomotor skills are "hands-on" skills, which
are often procedures and are evaluated by return demonstration. Cognitive skills are the
intellectual skills of analysis and problem-solving and are evaluated by tests.
During which part of the client interview would it be best for the nurse to ask, "What's
the weather forecast for today?"
A. Introduction
B. Body
C. Closing
D. Orientation - Answers>>A. Introduction
Rationale: Asking about the weather initiates the social or introductory phase of the
interview and allows the nurse to begin an assessment of the client's mental status. The
goal is to develop rapport with the client at the beginning of the interview. In the body
the client responds to the nurse's questions. During the closing the nurse or the client
terminates the interview.
For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral
fractured wrists in casts, what is the major related factor or risk factor identified by the
nurse?
A. Discomfort
B. Deficit
C. Feeding
D. Fractured wrists - Answers>>D. Fractured Wrists
Rationale: The etiology or related factors of a nursing diagnostic statement define one
or more probable causes of the problem and allow the nurse to individualize the client's
care. In this case, the fracture is the cause of the client's feeding problem.
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 - Answers>>C. Include the client
and family when setting goals and formulating the plan of care
Process 2025
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While
taking the client's vital signs, the nurse is implementing which phase of the nursing
process?
A. Assessment
B. Diagnosis
C. Planning
D. Implementation - Answers>>A. Assessment
Rationale: The first step in the nursing process is assessment, the process of collecting
data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on
accurate and complete data.
A client on the nursing unit is terminally ill but remains alert and oriented. Three days
after admission, the nurse observes signs of depression. The client states, "I'm tired of
being sick. I wish I could end it all." What is the most accurate and informative way to
record this data in a nursing progress note?
A. Client appears to be depressed, possibly suicidal
B. Client reports being tired of being ill and wants to die
C. Client does not want to live any longer and is tired of being ill
D. Client states, "I'm tired of being sick. I wish I could end it all." - Answers>>D. Client
states, "I'm tired of being sick. I wish I could end it all."
Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and
sensations that are apparent only to the person affected and cannot be measured,
seen, or felt by the nurse. This information should be documented using the client's
exact words in quotes. The other options indicate that the nurse has drawn the
conclusion that the client no longer wishes to live. From the data provided, the cues do
not support this assumption. A more complete assessment should be conducted to
determine if the client is suicidal.
A client who complains of nausea and seems anxious is admitted to the nursing unit.
The nurse should take which of the following actions regarding completion of the
admission interview?
A. Help the client to get settled and do the interview the next morning when the client is
rested
B. Do the interview immediately, directing the majority of the questions to the client's
spouse
C. Do the interview as soon as some uninterrupted time is available in order to address
the client's concerns
,D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor
for anti-nausea and anti-anxiety medication - Answers>>C. Do the interview as soon as
some uninterrupted time is available in order to address the client's concerns
Rationale: To collect data accurately, the client must participate. Attending to the client's
immediate personal needs before expecting the client to focus on the interview will
maximize the accuracy of the data collected. Data should be collected shortly after
admission. The best source of data is the client. The management of the client's anxiety
is the responsibility of the nurse conducting the interview and initiating the relationship.
A desired outcome for a client immobilized in a long leg cast reads; Client will state
three signs of impaired circulation prior to discharge. When the nurse evaluates the
client's progress, the client is able to state that numbness and tingling are signs of
impaired circulation. What would be an appropriate evaluation statement for the nurse
to write?
A. Client understands the signs of impaired circulation
B. Goal met: Client cited numbness and tingling as sign of impaired circulation
C. Goal not met: Client able to name only two signs of impaired circulation
D. Goal not met: Client unable to describe signs of impaired circulation - Answers>>C.
Goal not met: Client able to name only two signs of impaired circulation
Rationale: The goal has not been met because the client states only two out of three
signs of impaired circulation. By comparing the data with the expected outcomes, the
nurse judges that while there has been progress toward the goal, it has not been
completely met. The care plan may need to be revised or more effective teaching
strategies may need to be implemented to achieve the goal.
A nurse explains to a student that the nursing process is a dynamic process. Which of
the following actions by the nurse best demonstrates this concept during the work shift?
A. Nurse and client agree upon health care goals for the client
B. Nurse reviews the client's history on the medical record
C. Nurse explains to the client the purpose of each administered medication
D. Nurse rapidly reset priorities for client care based on a change in the client's
condition - Answers>>D. Nurse rapidly reset priorities for client care based on a change
in the client's condition
Rationale: The nursing process is characterized by unique properties that enable it to
respond to the changing health status of the client. Options 1, 2, and 3 are appropriate
nursing care measures, but do not demonstrate the dynamic nature of the nursing
process.
After instructing the client on crutch walking technique, the nurse should evaluate the
client's understanding by using which of the following methods?
, A. Return demonstration
B. Explanation
C. Achievement of 90 on written test
D. Have client explain produce to the family - Answers>>A. Return demonstration
Rationale: Interpersonal skills are the sum of the activities the nurse uses when
communicating with others. Technical/psychomotor skills are "hands-on" skills, which
are often procedures and are evaluated by return demonstration. Cognitive skills are the
intellectual skills of analysis and problem-solving and are evaluated by tests.
During which part of the client interview would it be best for the nurse to ask, "What's
the weather forecast for today?"
A. Introduction
B. Body
C. Closing
D. Orientation - Answers>>A. Introduction
Rationale: Asking about the weather initiates the social or introductory phase of the
interview and allows the nurse to begin an assessment of the client's mental status. The
goal is to develop rapport with the client at the beginning of the interview. In the body
the client responds to the nurse's questions. During the closing the nurse or the client
terminates the interview.
For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral
fractured wrists in casts, what is the major related factor or risk factor identified by the
nurse?
A. Discomfort
B. Deficit
C. Feeding
D. Fractured wrists - Answers>>D. Fractured Wrists
Rationale: The etiology or related factors of a nursing diagnostic statement define one
or more probable causes of the problem and allow the nurse to individualize the client's
care. In this case, the fracture is the cause of the client's feeding problem.
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 - Answers>>C. Include the client
and family when setting goals and formulating the plan of care
