Nursing Process NCLEX Questions

Correct Answer: A

Rationale: The correct answer is A: Anxiety related to barium enema. This is the correct choice because nursing diagnoses should focus on the patient's actual or potential health problems, not just medical conditions. Anxiety is a common response to medical procedures like a barium enema. It is essential for the nurse to address the patient's emotional and psychological needs. Summary: B: Impaired gas exchange related to asthma is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on the patient's response to the medical condition. C: Impaired physical mobility related to incisional pain is a potential nursing diagnosis, but the focus should be on the patient's response to the pain, not just the pain itself. D: Nausea related to adverse effect of cancer medication is also a medical diagnosis. Nursing diagnoses should address the patient's response to the medication side effects, not just the side effects themselves.

Correct Answer: A

Rationale: The correct answer is A because the first phase of the nursing process is assessment, where the nurse gathers comprehensive data about the patient's health status. This step is crucial in identifying problems and setting priorities for care. Choice B comes in the second phase (diagnosis), C in the third phase (planning), and D in the last phase (evaluation). Assessing the patient's condition is the foundation for the rest of the nursing process.

Correct Answer: B

Rationale: The correct answer is B (126mg/dl) because a fasting plasma glucose level ?126mg/dl is diagnostic of diabetes. The diagnostic criteria for diabetes include a fasting plasma glucose level ?126mg/dl on two separate occasions. Choices A, C, and D are incorrect because they do not meet the diagnostic threshold for diabetes. A (90mg/dl) is within the normal range, C (115mg/dl) is elevated but not diagnostic, and D (180mg/dl) is too high but not necessary for diagnosis. It's crucial to understand the specific diagnostic criteria to accurately identify diabetes.

Correct Answer: A

Rationale: The correct answer is A because it reflects a measurable and client-centered outcome. Verbalizing feelings of anxiety indicates the client is acknowledging and addressing their emotions, which is essential in managing anxiety. Choice B is incorrect as it focuses on avoidance rather than expression of emotions. Choice C is incorrect as it doesn't specify the use of appropriate coping mechanisms. Choice D is incorrect as it suggests avoidance of seeking information, which may hinder the client's understanding and coping with the diagnosis.

Correct Answer: C

Rationale: The correct answer is C: Osteoporosis. Long-term corticosteroid therapy, such as prednisone, is known to cause bone loss and increase the risk of osteoporosis. Corticosteroids inhibit bone formation and increase bone resorption, leading to decreased bone density and increased fracture risk, which can manifest as severe back pain. Incorrect choices: A: Hypertension - Corticosteroids can cause fluid retention and sodium retention, leading to hypertension, but it is not typically associated with severe back pain. B: Muscle wasting - Corticosteroids can lead to muscle weakness, but severe back pain is not typically related to muscle wasting. D: Truncal obesity - Corticosteroids can cause weight gain, especially in the trunk area, but this is not directly responsible for severe back pain.