Assessment
A patient tells the nurse, “I feel really anxious about returning home alone after surgery.” Vital signs are within normal limits, and the surgical incision is healing well. What can the nurse infer from this statement?
A. The patient is experiencing a physical complication
B. The patient is expressing an emotional concern
C. The patient’s pain is poorly controlled
D. The patient is at risk for infection
Answer: B. The patient is expressing an emotional concern
Rationale:
Subjective data are based on the patient’s feelings, perceptions, or concerns. The statement reflects fear and anxiety, which are emotional responses, not objective physical findings.
A patient reports frequent loose stools over the past two days. Which question is most appropriate for the nurse to ask to help establish a nursing diagnosis of Diarrhea?
A. “Do you have any allergies to medications?”
B. “How many times have you had a bowel movement today?”
C. “Do you exercise regularly?”
D. “What is your family medical history?”
Answer: B. “How many times have you had a bowel movement today?”
Rationale:
Specific questions about frequency, consistency, and duration of stools provide data to support a nursing diagnosis of diarrhea. Questions unrelated to bowel patterns are not directly helpful.
A nurse is caring for a patient with Impaired Skin Integrity due to immobility. Which intervention is most appropriate to prevent further skin breakdown?
A. Reposition the patient every 2 hours
B. Encourage high-protein snacks once per day
C. Apply lotion only when the patient complains of dry skin
D. Keep the patient in a semi-Fowler’s position at all times
Answer: A. Reposition the patient every 2 hours
Rationale:
Frequent repositioning relieves pressure and reduces shear forces, which is essential in preventing further skin breakdown. Other options may support overall health but do not directly address impaired skin integrity.
A patient with mild hypertension is prescribed a new antihypertensive medication. Which action demonstrates the nurse is using critical thinking during implementation of care?
A. Administering the medication without reviewing the patient’s current vital signs
B. Reviewing the patient’s blood pressure and allergies before giving the medication
C. Following the medication schedule exactly without considering patient condition
D. Delegating the medication administration without checking orders
Answer: B. Reviewing the patient’s blood pressure and allergies before giving the medication
Rationale:
Critical thinking involves assessing patient-specific factors, such as vital signs and allergies, before implementing an intervention. Blindly following orders or delegating without verification does not demonstrate critical thinking.
A patient has a nursing care plan with the goal: “Patient’s blood pressure will be less than 130/80 mmHg by 12/3.” During morning assessment, the patient’s blood pressure is 128/78 mmHg. What does this finding indicate?
A. The patient’s goal has been met
B. The patient requires an adjustment in medication
C. The patient is at risk for hypotension
D. The patient’s condition is deteriorating
Answer: A. The patient’s goal has been met
Rationale:
The patient’s blood pressure is below the target goal, indicating the expected outcome has been achieved.
While assessing a patient, the nurse observes the following: heart rate 102 bpm, incision site is red and slightly swollen, and the patient is rubbing their abdomen and reports discomfort. Which of these is considered objective data?
A. Patient reports abdominal discomfort
B. Patient expresses concern about pain
C. Heart rate of 102 bpm
D. Patient states, “I feel uneasy about the healing process”
Answer: C. Heart rate of 102 bpm
Rationale:
Objective data are measurable or observable signs, such as vital signs, physical findings, or lab results. Subjective data reflect the patient’s personal experiences or feelings.
A patient presents to the emergency department after a motor vehicle accident with a right femur fracture. The leg is immobilized in a full-leg cast. The patient is otherwise healthy and reports only moderate discomfort. Which nursing diagnosis is most pertinent to include in the plan of care?
A. Risk for Infection
B. Acute Pain
C. Ineffective Coping
D. Imbalanced Nutrition: Less than Body Requirements
Answer: B. Acute Pain
Rationale:
The patient’s primary and immediate need is pain management due to the fracture and immobilization. While infection and nutrition may be secondary concerns, the most urgent and pertinent nursing diagnosis is acute pain.
A novice nurse writes the following outcome statement for a patient at risk for falls: “Patient will be safe while in the hospital.” Which statement demonstrates a SMART outcome?
A. Patient will remain free from falls during hospitalization.
B. Patient will demonstrate safe ambulation with a walker within 48 hours.
C. Patient will feel safe at all times.
D. Patient will be careful when walking.
Answer: B. Patient will demonstrate safe ambulation with a walker within 48 hours
Rationale:
SMART outcomes are Specific, Measurable, Achievable, Relevant, and Time-bound. Option B meets all criteria; the other statements are vague, subjective, or lack a time frame.
A patient reports sudden onset of chest pain radiating to the left arm and jaw. Vital signs show BP 150/90 mmHg, HR 110 bpm. Which initial intervention is most appropriate?
A. Encourage the patient to take deep breaths and relax
B. Obtain a 12-lead ECG and notify the healthcare provider
C. Offer water and a snack to stabilize blood sugar
D. Instruct the patient to ambulate to the restroom
Answer: B. Obtain a 12-lead ECG and notify the healthcare provider
Rationale:
New-onset chest pain may indicate myocardial ischemia. Immediate assessment and provider notification are critical to prevent complications. Relaxation, food, or ambulation are inappropriate at this time.
A patient complains of moderate headache pain. The nurse administers acetaminophen 650 mg orally. Which action is the nurse’s priority?
A. Document the medication in the MAR
B. Assess the patient’s pain level after the medication takes effect
C. Offer the patient water to swallow the tablet
D. Notify the provider immediately
Answer: B. Assess the patient’s pain level after the medication takes effect
Rationale:
Evaluation of effectiveness is a priority nursing action after administering a medication. Documentation and offering water are necessary, but they do not evaluate therapeutic effect. Immediate provider notification is not indicated unless complications arise.
During an admission interview, the nurse notices a patient of Middle Eastern descent avoids direct eye contact and keeps their hands folded while speaking. What is the most appropriate action for the nurse?
A. Instruct the patient to maintain eye contact for accurate assessment
B. Recognize this as a cultural behavior and continue the interview respectfully
C. Assume the patient is hiding information or being dishonest
D. Document the patient’s behavior as noncompliant
Answer: B. Recognize this as a cultural behavior and continue the interview respectfully
Rationale:
Eye contact norms vary across cultures. Nurses should be culturally sensitive and avoid misinterpreting behavior as noncompliance or dishonesty.
A patient with a history of diabetes reports numbness and tingling in the feet, difficulty walking, and occasional burning pain. Which NANDA-I approved nursing diagnosis is most appropriate for this patient?
A. Impaired Physical Mobility
B. Risk for Peripheral Neuropathy
C. Activity Intolerance
D. Impaired Sensory Perception
Answer: D. Impaired Sensory Perception
Rationale:
Impaired sensory perception is a NANDA-I approved diagnosis for patients with neuropathy affecting the ability to receive or interpret sensory stimuli. “Risk for peripheral neuropathy” is not an approved nursing diagnosis, and activity intolerance or impaired mobility may be secondary but not the primary focus.
After completing a thorough assessment and identifying nursing diagnoses, which step should the nurse take next in the nursing process?
A. Evaluate patient outcomes
B. Plan interventions to achieve desired outcomes
C. Implement nursing interventions
D. Reassess the patient
Answer: B. Plan interventions to achieve desired outcomes
Rationale:
The nursing process is sequential: assessment → diagnosis → planning → implementation → evaluation. Planning interventions comes after analyzing data and formulating nursing diagnoses.
A nurse is caring for a patient with diabetes who is scheduled for surgery. Which action demonstrates critical thinking when implementing the patient’s care?
A. Administering morning insulin without checking blood glucose
B. Reviewing the patient’s blood glucose level, NPO status, and surgery time before administering insulin
C. Skipping insulin because the patient will be NPO
D. Giving insulin at the usual time without consulting the provider
Answer: B. Reviewing the patient’s blood glucose level, NPO status, and surgery time before administering insulin
Rationale:
Critical thinking requires integrating multiple patient-specific factors to safely implement interventions. Blind administration without assessment can cause hypoglycemia or harm.
A patient has a stage II pressure injury on the sacrum. Which observation would indicate the wound is progressing toward healing?
A. Presence of granulation tissue in the wound bed
B. Wound edges appear macerated and pale
C. Increased serosanguinous drainage
D. Foul odor from the wound
Answer: A. Presence of granulation tissue in the wound bed
Rationale:
Granulation tissue is a positive sign of wound healing. Maceration, increased drainage, and foul odor may indicate infection or delayed healing.
A patient recovering from hip surgery says, “I feel unsteady and scared to walk without help,” while gripping the walker tightly. Vital signs are stable, and there are no new physical complications. What is the nurse’s most appropriate inference?
A. The patient requires additional pain medication
B. The patient is experiencing mobility-related anxiety
C. The patient is at high risk for infection
D. The patient is ready for independent ambulation
Answer: B. The patient is experiencing mobility-related anxiety
Rationale:
The patient’s fear and grip on the walker reflect emotional concerns about mobility. Although vitals are stable and no complications exist, emotional support and safe ambulation planning are needed.
A 65-year-old patient reports diarrhea for the past 3 days, accompanied by mild abdominal cramping, fatigue, and dry mucous membranes. Vital signs are: BP 98/60 mmHg, HR 110 bpm, T 99.0°F. Which nursing diagnosis should the nurse prioritize?
A. Deficient Fluid Volume
B. Chronic Pain
C. Risk for Impaired Skin Integrity
D. Anxiety
Answer: A. Deficient Fluid Volume
Rationale:
The patient’s diarrhea, tachycardia, hypotension, and dry mucous membranes indicate fluid loss and dehydration. This requires immediate intervention. Chronic pain, skin integrity, and anxiety are less urgent in this scenario.
A nurse is developing a care plan for a patient with Impaired Skin Integrity due to prolonged immobility and friction. Which intervention demonstrates the most effective approach?
A. Apply hydrocolloid dressing to pressure points and reposition the patient every 2 hours
B. Encourage the patient to take multivitamins daily
C. Perform daily skin assessments and record observations once per week
D. Apply lotion to the entire body without repositioning
Answer: A. Apply hydrocolloid dressing to pressure points and reposition the patient every 2 hours
Rationale:
Combining protective dressings with frequent repositioning addresses both pressure and friction/shear forces. Simple lotion or infrequent assessments are insufficient to prevent further skin damage.
A patient with chronic obstructive pulmonary disease (COPD) presents with shortness of breath, wheezing, and an oxygen saturation of 88%. The patient is prescribed oxygen, a nebulizer treatment, and medications as ordered. Which action demonstrates the nurse is using critical thinking in implementing care?
A. Administer all treatments simultaneously without assessing priority
B. Assess lung sounds and oxygen saturation before deciding which intervention to administer first
C. Wait until the next scheduled medication time to administer the treatments
D. Delegate all treatments to NAP without providing instructions
Answer: B. Assess lung sounds and oxygen saturation before deciding which intervention to administer first
Rationale:
Critical thinking involves assessing the patient’s current status and prioritizing interventions based on the most urgent needs, such as oxygenation. Administering interventions without assessment or delegating without instructions could compromise patient safety.
A patient with hypertension has an expected outcome: “Patient’s systolic blood pressure will remain below 140 mmHg within 48 hours.” During the evening assessment, the patient’s blood pressure is 142/88 mmHg, and the patient reports mild dizziness. What is the nurse’s best action?
A. Document that the goal has not been met and continue routine care
B. Reassess the blood pressure, review medications, and notify the healthcare provider if needed
C. Encourage the patient to ambulate to improve circulation
D. Wait until the next scheduled check to evaluate progress
Answer: B. Reassess the blood pressure, review medications, and notify the healthcare provider if needed
Rationale:
The nurse must verify findings, consider contributing factors, and notify the provider to prevent complications. This reflects safe prioritization and critical thinking in outcome evaluation.
A nurse is conducting a comprehensive assessment on an older adult patient from an East Asian background. The patient speaks softly, avoids eye contact, and pauses frequently before answering questions. Which nursing actions are appropriate? (Select all that apply.)
A. Use open-ended questions to allow the patient time to respond
B. Encourage the patient to make eye contact immediately
C. Observe both verbal and nonverbal cues for understanding
D. Document cultural behaviors accurately without judgment
E. Assume hesitation indicates confusion or cognitive impairment
Answer: A, C, D
Rationale:
Cultural competence requires respecting communication styles, including soft speech, avoidance of eye contact, and pauses. Nurses should provide time to respond, observe nonverbal cues, and document behaviors accurately. Forcing eye contact or assuming confusion may misinterpret cultural norms.
A nurse is preparing a care plan for a patient admitted with congestive heart failure and mild dyspnea at rest. The patient also reports difficulty sleeping due to nocturnal shortness of breath and swelling in the ankles. Which of the following are appropriate NANDA-I approved nursing diagnoses for this patient? (Select all that apply.)
A. Impaired Gas Exchange
B. Activity Intolerance
C. Ineffective Coping
D. Risk for Impaired Skin Integrity
E. Deficient Knowledge
Answer: A, B, D
Rationale:
Impaired Gas Exchange: Due to dyspnea and fluid overload affecting oxygenation.
Activity Intolerance: Patient reports fatigue and shortness of breath with activity.
Risk for Impaired Skin Integrity: Swelling in the ankles increases risk for skin breakdown.
Ineffective Coping: Not directly indicated by the scenario.
Deficient Knowledge: No information is provided suggesting the patient lacks knowledge.
A nurse is creating a care plan for a patient with Impaired Mobility after a stroke. Which actions reflect appropriate steps in the nursing process and SMART outcome planning? (Select all that apply.)
A. Identify nursing diagnoses based on patient assessment
B. Write an outcome statement: “Patient will walk 50 feet with a cane within 5 days”
C. Implement interventions, such as assisted ambulation and physical therapy
D. Document subjective feelings of frustration without planning interventions
E. Evaluate the patient’s ability to meet the planned outcomes after 5 days
Answer: A, B, C, E
Rationale:
Effective nursing care plans require:
Assessment and diagnosis (A)
SMART outcome statements (B)
Implementation of interventions (C)
Evaluation of outcomes (E)
Option D is incomplete and does not reflect planning, implementation, or measurable outcomes.
A nurse is caring for multiple patients on a medical-surgical unit. Which actions demonstrate the nurse is using critical thinking when implementing care? (Select all that apply.)
A. Checking a patient’s allergy history before administering a new antibiotic
B. Evaluating a patient’s pain level and vital signs before giving PRN pain medication
C. Administering medications in the order they appear on the MAR without considering patient condition
D. Prioritizing interventions for a patient with new-onset chest pain over routine care tasks
E. Documenting care interventions only at the end of the shift
Answer: A, B, D
Rationale:
Critical thinking includes assessing patient-specific factors (A, B) and prioritizing interventions based on urgency (D). Administering medications without considering condition (C) and delaying documentation (E) are unsafe practices.
A nurse is evaluating the progress of a patient with a stage III pressure ulcer on the heel. Which findings indicate that the patient’s expected outcomes for wound healing are being met? (Select all that apply.)
A. Wound bed shows beefy red granulation tissue
B. Wound size has decreased by 25% over 1 week
C. Surrounding skin appears intact and without redness
D. Foul odor and purulent drainage are present
E. Patient reports reduced pain at the wound site
Answer: A, B, C, E
Rationale:
Positive indicators of wound healing include the presence of granulation tissue, reduction in wound size, intact surrounding skin, and decreased pain. Foul odor and purulent drainage suggest infection and delayed healing.