NCLEX 2022/2023 update QUESTIONS AND ANSWERS ,NURSING PROCESS(100% Verified)

NCLEX 2022/2023 update QUESTIONS
AND ANSWERS: NURSING
PROCESS(100%
Verified)

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 Correct answer- 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.

The nurse is most likely to collect timely, specific information by asking which of the

following questions?

A. "Would you describe what you are feeling?"

B. "How are you today?"

C. "What would you like to talk about?"

D. "Where does it hurt?" Correct answer- A. "Would you describe what you are feeling?"

Rationale: This is an open-ended question that will elicit subjective data. The data

collected will reflect the client's current health status and human response(s) and should

generate specific information that can be used to identify actual and/or potential health

problems. Options 2 and 3 are more likely to elicit general, nonspecific information.

Option 4 may result in a brief, one-word response or nonverbal gesture indicating the

site of the client's pain. A better approach to collect specific information might be,

"Describe any pain you are having."

The nurse should avoid asking the client which of the following leading questions during

a client interview?

A. "What medication do you take at home?"

B. "You are really excited about the plastic surgery, aren't you?"

C. "Were you aware I've has this same type of surgery?"

D. "What would you like to talk about?" Correct answer- B. "You are really excited about

the plastic surgery, aren't you?"

Rationale: A leading question directs the client's answer. The phrasing of the question

indicates an expected answer. The client may be influenced by the nurse's expectations

and may give inaccurate responses. This process can result in an error in diagnostic

reasoning.

The nurse needs to validate which of the following statements pertaining to an assigned

client?

A. The client has a hard, raised, red lesion on his right hand.

B. A weight of 185 lbs. is recorded in the chart

C. The client reported an infected toe

D. The client's blood pressure is 124/70. It was 118/68 yesterday. Correct answer- C.

The client reported an infected tow

Rationale: Validation is the process of confirming that data are actual and factual. Data

that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse

should assess the client's toe to validate the statement.

Which of the following items of subjective client data would be documented in the

medical record by the nurse?

A. Client's face is pale

B. Cervical lymph nodes are palpable

C. Nursing assistant reports client refused lunch

D. Client feel nauseated Correct answer- D. Client feel nauseated

Rationale: Subjective data includes the client's sensations, feelings, and perception of

health status. Subjective data can only be verified by the affected person. Options 1, 2,

and 3 represent objective data that can be detected by the nurse or measured against

an accepted norm.

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 Correct answer- D. Nurse rapidly reset priorities for client care based on a

change in the client's conditio