A nurse performs an initial interview for a client who presents with manifestations consistent with Parkinson's disease. The nurse also interviews the client's family. Which of the following steps of the nursing process is the nurse completing?

Planning

Diagnosis

Evaluation

Assessment

Answer and Explanation

The Correct Answer is D

A. The planning step involves developing goals, expected outcomes, and interventions based on the identified nursing diagnoses. It occurs after data collection, not during the initial interview.

B. The diagnosis step requires the nurse to analyze assessment data to identify actual or potential health problems. The nurse cannot make a diagnosis until all relevant information has been gathered.

C. Evaluation occurs after interventions are implemented and focuses on determining whether the client’s goals and outcomes have been met. It does not apply to an initial interview situation.

D. This is the first step of the nursing process, in which the nurse collects and organizes data about the client’s physical, psychological, and social status. Interviewing the client and family to gather information about symptoms, history, and behaviors is part of the assessment phase.

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Correct Answer is B

Explanation

A. Family history increases the likelihood of developing certain diseases due to inherited genetic traits, but it is nonmodifiable because an individual cannot change their biological relatives or inherited risks.
B. Sunbathing exposes the skin to ultraviolet (UV) radiation, which increases the risk of skin cancer and premature aging. This behavior is modifiable because the client can reduce exposure by using sunscreen, wearing protective clothing, or avoiding excessive sun exposure—therefore helping to prevent disease.
C. Genetics determine an individual’s inherited characteristics and predisposition to diseases, which cannot be altered through lifestyle or environmental changes.
D. Age affects susceptibility to many diseases as the body’s physiological functions change over time, but it is nonmodifiable since it is beyond the individual’s control.

A. A client who is postoperative and has a urine output of 50 mL for the past 3 hr. B. A client who has early dementia and awoke confused to their location this morning. C. A client who has pneumonia and has developed wheezing D. A client who is scheduled for discharge and has a 38.4° C (101.1° F) temperature this morning.

Correct Answer is C

Explanation

A. This indicates decreased urine output (oliguria), which could suggest impaired renal perfusion or fluid imbalance. Although concerning, it does not take immediate priority over airway compromise.

B. This change is important to monitor but does not pose an immediate threat to airway, breathing, or circulation. The nurse can assess this client after stabilizing those with life-threatening conditions.

C. According to the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) priority framework, this client should be seen first because wheezing indicates airway narrowing or obstruction and impaired gas exchange. This poses an immediate threat to breathing, requiring prompt assessment and intervention (e.g., bronchodilators, oxygen therapy).

D. While the fever requires follow-up and may delay discharge, it is not an immediate life-threatening concern compared to airway compromise from wheezing.

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A nurse performs an initial interview for a client who presents with manifestations consistent with Parkinson's disease. The nurse also interviews the client's family. Which of the following steps of the nursing process is the nurse completing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as a modifiable risk factor for developing a disease?

Correct Answer is B

Explanation

A nurse is receiving report on a group of clients. Using the ABCDE priority framework, which of the following clients should the nurse see first?

Correct Answer is C

Explanation

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