Nursing Process Questions and Answers PDF

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A 19-year-old student develops symptoms of respiratory alkalosis related to an anxiety attack. Which nursing intervention is appropriate?

  • A. Make sure his oxygen is being administered as ordered.
  • B. Have him breathe into a paper bag.
  • C. Place him in a semi-fowler’s position.
  • D. Have him do coughing and deep breathing exercises.
Correct Answer: B

Rationale: The correct answer is B: Have him breathe into a paper bag. Breathing into a paper bag helps increase the carbon dioxide levels in the blood, which can help reverse respiratory alkalosis caused by hyperventilation during an anxiety attack. This intervention helps to normalize the blood pH and alleviate symptoms.

Incorrect choices:
A: Making sure oxygen is administered as ordered is not appropriate for respiratory alkalosis due to hyperventilation. Oxygen therapy can worsen the condition by further reducing carbon dioxide levels.
C: Placing the student in a semi-fowler's position does not directly address the primary issue of respiratory alkalosis and anxiety-induced hyperventilation.
D: Coughing and deep breathing exercises may exacerbate the hyperventilation and worsen the respiratory alkalosis rather than alleviate the symptoms.

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The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:

  • A. Active exercise
  • B. Use of tilt board
  • C. Deep massage
  • D. Proper positioning
Correct Answer: D

Rationale: The correct answer is D: Proper positioning. Proper positioning helps maintain joint alignment, prevents pressure ulcers, and reduces the risk of contractures by keeping the muscles in a neutral position. This is crucial in preventing complications associated with spasticity.

A: Active exercise may exacerbate spasticity and lead to muscle fatigue, increasing the risk of contractures.
B: Use of tilt board may not directly address the need for proper positioning to prevent contractures.
C: Deep massage may provide temporary relief but does not address the underlying issue of maintaining proper positioning to prevent contractures.

A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?

  • A. Act as a leader of the health care team.
  • B. Develop good communication skills.
  • C. Work solely with nurses.
  • D. Avoid conflict.
Correct Answer: B

Rationale: The correct answer is B: Develop good communication skills. In interdisciplinary collaboration, effective communication is essential for teamwork. By developing good communication skills, the nurse can effectively interact with other healthcare professionals to provide holistic care. Choice A is incorrect as the nurse should collaborate as part of a team, not necessarily be the leader. Choice C is incorrect as interdisciplinary collaboration involves working with professionals from various disciplines. Choice D is incorrect as conflict resolution is an important aspect of effective collaboration.

Which of the ff is the characteristic of a ketogenic diet that is suggested for children with seizures?

  • A. High carbohydrate diet
  • B. High fat diet
  • C. High protein diet
  • D. Low fat diet
Correct Answer: B

Rationale: Correct Answer: B (High fat diet)

Rationale:
1. Ketogenic diet for seizures aims to produce ketones for brain energy, achieved through high fat intake.
2. High fat intake helps induce ketosis, which may help reduce seizures in some children.

Incorrect Choices:
A: High carbohydrate diet - Contradicts the purpose of a ketogenic diet.
C: High protein diet - Excessive protein can hinder ketosis and is not the primary focus of a ketogenic diet.
D: Low fat diet - Opposite of the high fat requirement for a ketogenic diet to induce ketosis.

A client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?

  • A. Stool hematest
  • B. Abdominal computed tomography (CT)
  • C. Carcinoembryonic antigen (CEA) scan
  • D. Sigmoidoscopy
Correct Answer: D

Rationale: The correct answer is D: Sigmoidoscopy. This procedure allows direct visualization of the lower colon and rectum, enabling the detection of colorectal cancer. Stool hematest (A) detects blood in the stool but does not confirm cancer. Abdominal CT (B) can show abnormalities but is not specific for colorectal cancer. CEA scan (C) measures a tumor marker but is not definitive for diagnosis. Sigmoidoscopy (D) is the gold standard for diagnosing colorectal cancer as it allows for direct visualization and tissue biopsy.

When testing visual fields, the nurse is assessing which of the following parts of vision?

  • A. Peripheral vision
  • B. Distance vision
  • C. Near vision
  • D. Central vision
Correct Answer: A

Rationale: The correct answer is A: Peripheral vision. When testing visual fields, the nurse evaluates the ability to see objects outside the direct line of sight, which is indicative of peripheral vision. Peripheral vision helps detect objects and movement in the side vision. Distance vision (B) refers to the ability to see clearly at a distance, while near vision (C) pertains to close-up vision. Central vision (D) is essential for focusing on details and seeing straight ahead. Therefore, A is the correct choice as it specifically pertains to the assessment of visual fields.

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