which of the following questions must the nurse ask when formulating a nursing diagnosis which of the following questions must the nurse ask when formulating a nursing diagnosis
Logo

Nursing Elites

NCLEX NCLEX-RN

Saunders NCLEX RN Practice Questions

1. What question must the nurse ask when formulating a nursing diagnosis?

Correct answer: What is the issue that I can solve for this client?

Rationale: When formulating a nursing diagnosis, the nurse should focus on identifying the client's specific health problems that can be addressed through nursing interventions. The correct answer emphasizes the nurse's role in identifying and addressing client-specific issues through nursing care. Choice A is incorrect because nursing diagnoses are distinct from medical diagnoses made by physicians. Choice C is incorrect as it focuses on physician orders rather than the nurse's role in diagnosing and addressing client problems. Choice D is incorrect because it pertains to identifying underlying diseases, which is not the primary focus of nursing diagnoses.

2. A patient’s chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute?

Correct answer: Migraines

Rationale: The correct answer is 'Migraines.' Migraines are not a symptom typically associated with hyperkalemia. In acute hyperkalemia, one would not expect to see migraines. Symptoms of hyperkalemia often include muscle weakness, paresthesias, and cardiac manifestations such as bradycardia or even cardiac arrest. Therefore, choices A, B, and C are more commonly associated with acute hyperkalemia compared to migraines, making it the correct choice.

3. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?

Correct answer: Spinal column manipulation

Rationale: The focus of the nurse's response should be on spinal column manipulation when discussing chiropractic treatment for illnesses. Chiropractic theory emphasizes that misalignment of the vertebrae can interfere with the transmission of mental impulses between the brain and body organs, leading to diseases. Manipulation is aimed at reducing such misalignments, known as subluxations. While mind-body balance and exercise of joints are important aspects of holistic health, in the context of chiropractic treatment, the key intervention is spinal column manipulation to address vertebral misalignments. Therefore, choices A, C, and D are incorrect as they do not directly address the primary focus of chiropractic treatment.

4. After a mastectomy or a hysterectomy, a client may feel incomplete as a woman. Which statement would alert the nurse to this feeling in a client who has undergone a total hysterectomy?

Correct answer: "I feel washed out; there isn’t much left."

Rationale: The correct answer is "I feel washed out; there isn’t much left." This statement suggests a feeling of emptiness or incompleteness after the surgical procedure. Concern about who can assist during recovery, fear of pain, or excitement to go home and see a grandchild are not indicative of feeling incomplete as a woman after a hysterectomy. These other statements focus on practical concerns, physical discomfort, and positive emotions, respectively.

5. A daughter of a Chinese-speaking client approaches the nurse and asks multiple questions while maintaining direct eye contact. Which culturally related concept would the daughter’s behavior reflect?

Correct answer: Assimilation

Rationale: The correct answer is assimilation. Assimilation involves incorporating the behaviors of a dominant culture. In this scenario, maintaining eye contact is characteristic of the American or Canadian culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike, which is not demonstrated by the daughter's behavior. Ethnocentrism is the perception that one’s beliefs are superior to those of others, which is not evident in this situation.

Similar Questions

A mother brings her 5-week-old infant to the health care clinic and tells the nurse that the child has been vomiting after meals. The mother reports that the vomiting is becoming more frequent and forceful. The nurse suspects pyloric stenosis and asks the mother which assessment question to elicit data specific to this condition?
Which intervention would the nurse use to provide emotional support for a resident in a nursing home who recently immigrated from another country?
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
A child is diagnosed with Hirschsprung's disease. The nurse is teaching the parents about the cause of the disease. Which statement, if made by the parent, supports that teaching was successful?
What should be the initial action for a client admitted to an alcohol rehabilitation center who has a strong odor of alcohol on their breath on the fourth day after admission?

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99