1. A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be the priority , keeping in mind the client's condition? A. Risk for Activity Intolerance B. R ...

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1. A client with HIV has been admitted to a health care facility. Which nursing diagnosis
should be the priority , keeping in mind the client's condition?
A. Risk for Activity Intolerance
B. Risk for Ineffective Coping
C. Risk for Infection
D. Risk for Imbalanced Nutrition

Answer: C

Rationale: Clients with HIV have decreased immunity and are prone to infections. Infection
in a client with HIV is life -threatening, because it makes the client vulnerable to other
infections, and also impairs their already weakened immune functions. Clients with HIV may
not have problems with other activities and food. They may often feel depressed, but this is
not the highest priority.
Question format: Multiple Choice
Chapter 2: Nursing Process
Cognitive Level: Analyze
Cli ent Needs: Safe, Effective Care Environment: Management of Care
Integrated Process: Nursing Process
Reference: p. 25

2. A client is being prepared for cardiac catheterization. The nurse performs an initial
assessment and records the vital signs. Which dat a collected can be classified as subjective
data?
A. Blood pressure
B. Nausea
C. Heart rate
D. Respiratory rate

Answer: B

Rationale: Subjective data are those that only the client can experience and describe. Nausea
is subjective data, as it can only be described and not measured. Blood pressure, heart rate,
and respiratory rate are measurable factors and are therefore objective data.
Question format: Multiple Choice
Chapter 2: Nursing Process
Cognitive Level: Understand
Client Needs Pn: Physiological Integrity: Reduction of Risk Potential
Client Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process
Reference: p. 20

3. A client who has to undergo a parathyroidectomy is worried about possibly havin g to wear
a scarf around the neck after surgery. What nursing diagnosis should the nurse document in
the care plan?
A. Risk for Impaired Physical Mobility due to surgery
B. Ineffective Denial related to poor coping mechanisms
C. Disturbed Body Image relate d to the incision scar
D. Risk of Injury related to surgical outcomes

Test Bank - Timby’s Fundamental Nursing Skills and Concepts (12th by Moreno)
Chapter 2 - Nursing Process

Answer: C

Rationale: The client is concerned about the surgery scar on the neck, which would disturb
the client's body image; therefore, the appropriate diagnosis should be Disturbed B ody Image
related to the incision scar. Risk for Impaired Physical Mobility may be present after surgery,
but is not related to the concerns expressed by the client. Likewise, Ineffective Denial related
to poor coping mechanisms and Injury related to surgi cal outcomes are also not related to the
client's concern.
Question format: Multiple Choice
Chapter 2: Nursing Process
Cognitive Level: Apply
Client Needs: Psychosocial Integrity
Client Needs Pn