Nursing Process Test Bank

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A home care nurse is assessing a client who is taking prazosin (Minipress). Which statement by the client would support the nursing diagnosis of noncompliance with medication therapy?

  • A. “I don’t’d understand why I have to keep taking pills when my blood pressure is normal.”
  • B. “I can’t see the numbness on the label to know how much selt is in food.”
  • C. “I feel dizzy, I’ll skip my dose foe a few days.”
  • D. “If I have a cold, I shouldn’t take any over-the-counter remedies without consulting my doctor.”
Correct Answer: C

Rationale: Step 1: Identify the correct answer - C: “I feel dizzy, I’ll skip my dose for a few days.”
Step 2: Explanation - This statement indicates that the client is experiencing a known side effect of prazosin (dizziness) and plans to stop the medication temporarily without consulting the healthcare provider, showing noncompliance.
Step 3: Supporting details - Skipping doses can lead to ineffective treatment and potential health risks.
Step 4: Comparison with other choices:
A: This statement shows the client questioning the need for medication but does not indicate current noncompliance.
B: This statement demonstrates difficulty reading labels but does not directly relate to medication compliance.
D: This statement shows awareness about medication interactions but does not indicate noncompliance with the prescribed medication regimen.
Summary: Choice C is correct as it directly reflects noncompliance by planning to skip doses without consulting the healthcare provider, leading to potential adverse outcomes. Choices A, B, and D do not demonstrate the

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Patients with Guillain-Barre Syndrome should be closely monitored. Which of the ff. parameters is most important to be checked regularly for acute complications?

  • A. BUN and creatinine
  • B. Hgb and Hct
  • C. ABG
  • D. Serum potassium
Correct Answer: C

Rationale: The correct answer is C: ABG. Monitoring ABG in Guillain-Barre Syndrome patients is crucial as they are at risk for respiratory complications like respiratory failure due to muscle weakness. ABG provides information on oxygenation, ventilation, and acid-base balance. Regular monitoring helps detect early signs of respiratory distress and guide appropriate interventions.

A: BUN and creatinine are important for assessing renal function, but they do not directly relate to acute complications in Guillain-Barre Syndrome.
B: Hgb and Hct are markers for anemia, which is not a common acute complication in Guillain-Barre Syndrome.
D: Serum potassium levels are important, but ABG monitoring takes precedence in patients with Guillain-Barre Syndrome due to the risk of respiratory issues.

As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?

  • A. I know the hallucinations are parts of the disease
  • B. I told her she is wrong and I explained to her what is right
  • C. I help her do some tasks he cannot do for himself
  • D. Ill turn off the TV when we go to another room
Correct Answer: B

Rationale: The correct answer is B because it indicates a confrontational and potentially disrespectful attitude towards the nurse. This response does not promote a collaborative and respectful communication between the daughter and the nurse. In a healthcare setting, it is important for family members to communicate effectively and respectfully with the healthcare team to ensure the best care for the patient.

A: This statement shows understanding and acceptance of the symptoms of the disease, indicating good knowledge.
C: This statement shows willingness to help the patient with tasks he cannot do for himself, which is a positive and caring attitude.
D: This statement shows consideration for the patient's needs by planning to turn off the TV when moving to another room, which is appropriate.

Pulmonary complications are the most common problem in caring for AIDS patients. This is caused:

  • A. Kaposi's Sarcoma
  • B. Pneumonia Carnii
  • C. Filterable Virus
  • D. Staphylococcus bacteria
Correct Answer: B

Rationale: The correct answer is B: Pneumonia Carnii. Pulmonary complications in AIDS patients are commonly caused by Pneumocystis jirovecii (previously known as Pneumocystis carinii) pneumonia. This opportunistic infection targets the lungs of immunocompromised individuals, leading to severe respiratory issues. Kaposi's Sarcoma (A) is a cancer commonly seen in AIDS patients but does not directly cause pulmonary complications. Filterable Virus (C) is a vague term and not a known cause of pulmonary issues in AIDS patients. Staphylococcus bacteria (D) can cause infections in AIDS patients but is less common than Pneumocystis jirovecii pneumonia in causing pulmonary complications.

The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:

  • A. Act as a vasoconstrictor
  • B. Block beta stimulation in the heart
  • C. Act as a vasodilator
  • D. Increase the heart rate
Correct Answer: B

Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking beta-1 and beta-2 receptors in the heart. By doing so, it reduces the heart rate, decreases the force of contraction, and lowers blood pressure, which helps in managing angina. Option A is incorrect because propranolol does not act as a vasoconstrictor. Option C is incorrect because propranolol does not act as a vasodilator. Option D is incorrect because propranolol decreases the heart rate rather than increasing it.

A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? “This system can help medical students determine the cost of the care they provide to

  • A. patients.” “If the nursing department uses this system, communication among nurses who work
  • B. throughout the hospital may be enhanced.” “We could use this system to help organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our
  • C. unit.” “The NIC system provides one way to improve safe and effective documentation in the
  • D. hospital’s electronic health record.”
Correct Answer: A

Rationale: The correct answer is A because the Nursing Interventions Classification (NIC) system is not designed to help medical students determine the cost of care. The NIC system focuses on standardizing and categorizing nursing interventions to improve communication, documentation, and patient care. Choice B is incorrect because it correctly identifies one of the benefits of using the NIC system - enhancing communication among nurses. Choice C is incorrect because it suggests a valid use of the NIC system for organizing orientation and explaining nursing interventions. Choice D is incorrect because it accurately states that the NIC system can improve documentation in the electronic health record, which is one of its purposes.

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