A)
B)
C)
D)
[Link] nurse is working with a patient to identify health goals and interventions to achieve
the goals. In which phase of the nursing process are the nurse and patient participating?
Assessment
Diagnosis
Planning
Evaluation
A)
B)
C)
D)
[Link] nurse is changing a patient's plan of care because identified goals have not been
achieved. The nurse is working within which phase of the nursing process?
Assessment
Planning
Implementation
Evaluation
A)
B)
C)
D)
[Link] an assessment, the nurse asks a patient with low back pain what has been used to
try to alleviate the pain. The nurse is asking questions to determine which category of the
mnemonic OLD CART?
Treatments
Duration
Location
Onset
A)
B)
C)
D)
[Link] nurse is completing an assessment of a patient with cardiac and respiratory problems.
Which data would the nurse categorize as subjective?
Blood pressure 168/94 mm Hg
Respiratory rate 28 and shallow
Heart rate 94 and irregular
Palpitations every morning
A)
B)
C)
D)
[Link] completing an assessment, the nurse is generating the patient's problem list. Which
problem would have the highest priority for the patient?
Shoulder pain
Insomnia
Anxiety about work
Lack of appetite
A)
B)
C)
D)
[Link] nurse has identified that a patient has 24 health issues to be included on the problem
list. What can the nurse do to help focus on the patient's most acute health care needs
first?
Place the problems in alphabetical order.
Separate the list into active and inactive problems.
List the problems according to body system.
Ask the patient which problem is the highest priority.
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A)
B)
C)
D)
[Link] nurse is determining diagnoses that would be appropriate for a patient with heart
failure. Which diagnosis would have the highest priority for the patient?
Activity intolerance related to shortness of breath and fatigue
Ineffective health maintenance related to last mammogram being 2 years ago
Knowledge deficit related to lack of information regarding low-sodium diet
Anxiety related to hospitalization and inability to attend to home and work needs
A)
B)
C)
D)
E)
[Link] nurse is developing nursing diagnosis for a patient. Which health concerns would be
appropriate for the nurse to identify as health maintenance problems? (Select all that
apply.)
Prescribed medication to treat prostate cancer
Instruction needed on newly prescribed renal diet
Importance of having pneumococcal pneumonia vaccination
Exercises for range of motion and mobility due to arthritis
Schedule for hemodialysis to start three times each week
A)
B)
C)
D)
[Link] nurse has completed a plan of care for a patient having a total knee replacement.
What should the nurse do prior to implementing this plan of care?
Discuss the plan of care with the nurse manager.
Share the assessment and plan with the admitting health care provider.
Ask the patient for opinions and willingness to proceed with the interventions.
Identify which quality improvement activities will be included in the plan of care.
A)
B)
C)
D)
E)
[Link] reassessing a patient with a foot wound, the nurse identifies a new health problem
of reduced breath sounds in both lung bases. What should the nurse do with this
information? (Select all that apply.)
Notify the nurse manager.
Formulate a nursing diagnosis.
Add interventions to the care plan.
Add the new problem to the problem list.
Nothing because this is an expected finding.
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Answer Key
1.C
2.D
3.A
4.D
5.A
6.B
7.A
8.B, C, D
9.C
10.B, C, D
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