NCLEX QUESTIONS NURSING PROCESS Exam with Correct Answers
During which part of the client interview would it be best for the nurse to ask, "What's the
... [Show More] 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 pertg 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. [Show Less]