Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is meeting with a client who has been treated at a substance use disorder clinic for three months. The client has had two follow up appointments at the clinic since their first visit, has attended a community-based peer support group twice weekly, and has taken their prescribed medication as directed. The nurse is discussing the effectiveness of these interventions with the client. The nurse is completing which of the following phases of the nursing process?
A. Analysis/diagnosis
Analysis/diagnosis involves identifying health problems based on assessment data.
B. Evaluation
Evaluation involves assessing the effectiveness of the interventions and progress towards goals, which is what the nurse is doing.
C. Implementation
Implementation refers to carrying out the plan of care.
D. Planning
Planning involves setting goals and determining the best interventions, which precedes implementation and evaluation.
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Full Explanation
A. Analysis/diagnosis involves identifying health problems based on assessment data.
B. Evaluation involves assessing the effectiveness of the interventions and progress towards goals, which is what the nurse is doing.
C. Implementation refers to carrying out the plan of care.
D. Planning involves setting goals and determining the best interventions, which precedes implementation and evaluation.
Similar Questions
A nurse is trying to encourage a client with paraplegia who is depressed and not adhering to the treatment program to join a support group. Which statement by the nurse is most appropriate?
A. "What do you know about support groups?"
Asking the client what they know about support groups is open-ended and encourages discussion.
B. “I am sure you would feel better if you joined a support group."
This statement is presumptive and may not be true for all clients.
C. "Support groups are for people like you who are depressed."
This statement is stigmatizing and may be perceived as judgmental.
D. “I am going to sign you up for a support group."
This statement takes away the client's autonomy and may lead to resistance.
Full Explanation
A. Asking the client what they know about support groups is open-ended and encourages discussion.
B. This statement is presumptive and may not be true for all clients.
C. This statement is stigmatizing and may be perceived as judgmental.
D. This statement takes away the client's autonomy and may lead to resistance.
On finding multiple bruises on a client's arms and back, the nurse suspects that the client is being abused by a daughter who lives with the client. When questioned, the client denies any abuse. Despite the client's denial, the nurse should report the suspected abuse on the basis of which rationale?
A. The nurse wants peers to see the nurse as a hero.
Reporting for personal recognition is not appropriate or ethical.
B. The nurse has a legal and ethical responsibility to report the suspected abuse.
Nurses are mandated reporters and have a legal and ethical duty to report suspected abuse.
C. The client does not want anyone to know what is happening in the client's home.
While the client may not want others to know, the nurse's responsibility is to ensure the client's safety.
D. The client is ashamed to admit to the abuse by the daughter.
Although the client may feel ashamed, the priority is their safety and wellbeing.
Full Explanation
A. Reporting for personal recognition is not appropriate or ethical.
B. Nurses are mandated reporters and have a legal and ethical duty to report suspected abuse.
C. While the client may not want others to know, the nurse's responsibility is to ensure the client's safety.
D. Although the client may feel ashamed, the priority is their safety and wellbeing.
A nurse is delegating client care assignments for the shift. Which of the following teks should the nurse delegate to an assistive personnel (AP)?
A. Measure and record intake and output for a client.
Measuring and recording intake and output is within the scope of practice for an AP.
B. Teach a client about low-sodium foods.
Teaching requires professional knowledge and is the responsibility of a nurse.
C. Evaluate pain relief for a client following the administration of a pain medication.
Evaluating pain relief requires critical thinking and assessment skills, which are within the nurse's scope of practice.
D. Perform wound irrigation for a client.
Wound irrigation is a skilled task that requires the expertise of a nurse.
Full Explanation
A. Measuring and recording intake and output is within the scope of practice for an AP.
B. Teaching requires professional knowledge and is the responsibility of a nurse.
C. Evaluating pain relief requires critical thinking and assessment skills, which are within the nurse's scope of practice.
D. Wound irrigation is a skilled task that requires the expertise of a nurse.