The basis for designing and selecting nursing interventions to meet client needs is the:

Nurse’s notes

Nursing diagnosis

Doctor’s orders

Care plan

Answer and Explanation

The Correct Answer is A

Choice A reason: This is incorrect because it shows that the nurse is not using a systematic and evidence-based approach to care. The nurse’s notes are a form of documentation, not a source of planning.

Choice B reason: This is correct because it shows that the nurse is using a systematic and evidence-based approach to care. The nursing diagnosis is a clinical judgment that identifies the client’s actual or potential health problems or needs and provides the basis for selecting appropriate interventions.

Choice C reason: This is incorrect because it shows that the nurse is not using a holistic and individualized approach to care. The doctor’s orders are a form of prescription, not a source of planning.

Choice D reason: This is incorrect because it shows that the nurse is confusing the outcome with the process. The care plan is a written document that outlines the goals, interventions, and evaluation of care, not a source of planning.

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Correct Answer is D

Explanation

D) “I understand that you would like some ice cream, but I need you to be more respectful when you ask me for something.” This is an assertive response because it acknowledges the patient’s request, expresses the nurse’s feelings, and sets a clear boundary for acceptable behavior. Assertiveness is the ability to communicate one’s needs, opinions, and feelings in a respectful and confident manner.

“You are hungry and want a snack. I can do that in 10 minutes when I finish my rounds.” is incorrect. This is a passive response because it does not address the patient’s rudeness or assert the nurse’s rights. Passive communication is the tendency to avoid conﬂict, suppress one’s feelings, and comply with others’ demands.

“Maybe I can get one of the aides to bring you something in a while.” is incorrect. This is an evasive response because it does not commit to fulfilling the patient’s request or confronting the patient’s attitude. Evasive communication is the tendency to avoid responsibility, give vague answers, and shift blame to others.

“Call the nursing station and ask them to have the kitchen bring whatever you want.” is incorrect. This is an aggressive response because it rejects the patient’s request, shows irritation, and implies that the nurse does not care about the patient’s needs. Aggressive communication is the tendency to dominate, criticize, and blame others.

A. Approximated wound edges B. Yellow, purulent drainage C. Pink granulation tissue D. Sutures in place

Correct Answer is A

Explanation

Choice A reason: This is incorrect because it shows that the wound is healing well. Approximated wound edges mean that the edges are close together and aligned.

Choice B reason: This is correct because it shows that the wound is infected. Yellow, purulent drainage means that the wound has pus, which is a sign of inﬂammation and bacterial growth.

Choice C reason: This is incorrect because it shows that the wound is healing well. Pink granulation tissue means that the wound has new blood vessels and connective tissue, which fill the wound space and promote healing.

Choice D reason: This is incorrect because it shows that the wound is stable. Sutures in place mean that the wound has been closed with stitches, which hold the edges together and prevent bleeding.

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The basis for designing and selecting nursing interventions to meet client needs is the:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

Correct Answer is D

Explanation

The nurse is changing a client’s dressing. Which observation warrants immediate physician notification?

Correct Answer is A

Explanation

A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client’s leg is pain free, without redness or edema. The nurse’s actions reﬂect which phase of the nursing process? Select one answer

A client with carotid stenosis has just discussed an upcoming surgery with the physician. The client tells the Practical Nurse (PN), “I wonder if I should let him cut my neck open?” Which nursing response is best?

When a female client preparing for surgery suddenly bursts into tears, the nurse should take which of the following actions? · Select one answer

Which statement best defines the nursing process? Select one answer

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The Practical Nurse (PN) is caring for a client with dementia and memory loss. Which of the following communication techniques would be most eﬀective? (Select all that apply)

Which of the following types of posture is best for the nurse to use when communicating with the patient? (Select all that apply)