Nursing Process Test Bank

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A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?

  • A. Allow her to ambulate unassisted, to encourage positive self-esteem.
  • B. Ask her to demonstrate her ability to ambulate.
  • C. Explain that someone will assist her as long as she is in the rehabilitation facility.
  • D. Ask another staff member to help ambulate the patient the first time.
Correct Answer: B

Rationale: The correct answer is B: Ask her to demonstrate her ability to ambulate. This response is best because it allows the nurse to assess the patient's actual ability to walk safely to the bathroom. By observing her, the nurse can ensure her safety and prevent potential falls. This approach also respects the patient's autonomy while prioritizing her safety.

Incorrect responses:
A: Allowing her to ambulate unassisted solely for positive self-esteem overlooks the importance of assessing her actual capability and ensuring safety.
C: Explaining that assistance will always be available may not address the immediate need for assessment and safety.
D: Asking another staff member to assist without assessing the patient's ability herself does not allow the nurse to directly evaluate the patient's safety and independence.

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Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?

  • A. Risk nursing diagnosis
  • B. Actual nursing diagnosis
  • C. Possible nursing diagnosis
  • D. Wellness diagnosis
Correct Answer: B

Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, which are signs and symptoms that support the diagnosis. This helps to differentiate it from other types of diagnoses such as risk, possible, or wellness diagnoses. Risk nursing diagnoses predict potential problems, possible nursing diagnoses lack sufficient data for validation, and wellness diagnoses focus on promoting health rather than addressing current health issues. Therefore, only the actual nursing diagnosis is confirmed by the presence of observable defining characteristics.

An African client has been diagnosed with Osteomyelitis. The nurse expects to assess which of the following?

  • A. pale, cool, tender skin at site
  • B. decreased white blood cell count
  • C. positive wound cultures
  • D. decreased erythrocyte sedimentation rate
Correct Answer: C

Rationale: The correct answer is C: positive wound cultures. Osteomyelitis is an infection of the bone that is typically diagnosed through wound cultures. This assessment helps to identify the causative organism and guide appropriate treatment. Choices A and D are not typical findings in osteomyelitis. Choice A describes symptoms of poor circulation which are not specific to osteomyelitis. Choice B, decreased white blood cell count, is typically not seen in the presence of an infection like osteomyelitis.

Immunity to a disease after recovery is possible because the first exposure to the pathogen has stimulated the formation of which of the following?

  • A. Antigens
  • B. Complement
  • C. Memory cells
  • D. Natural killer cells
Correct Answer: C

Rationale: The correct answer is C: Memory cells. After recovery from a disease, memory cells are formed as part of the adaptive immune response. These memory cells "remember" the pathogen and can mount a quicker and stronger immune response upon re-exposure. This results in immunity to the disease. Antigens (choice A) are substances that trigger the immune response but do not provide immunity on their own. Complement (choice B) is a group of proteins that enhance the immune response but do not directly lead to immunity. Natural killer cells (choice D) are part of the innate immune system and are not responsible for the specific memory response needed for immunity.

The clinical manifestations of Parkinson’s disease (bradykinesia rigidity and tremors) is directly related to a decreased level of:

  • A. Acetylcholine
  • B. Serotonin
  • C. Dopamine
  • D. Phenylalanine
Correct Answer: C

Rationale: The correct answer is C: Dopamine. Parkinson's disease is primarily caused by a deficiency of dopamine in the brain, leading to the characteristic symptoms of bradykinesia, rigidity, and tremors. Dopamine is a neurotransmitter involved in movement control. Acetylcholine (Choice A) is not directly related to Parkinson's disease, although its imbalance can contribute to other movement disorders. Serotonin (Choice B) and Phenylalanine (Choice D) are not primarily involved in the pathophysiology of Parkinson's disease.

When caring for Mr. Reyes, the nurse should assess for

  • A. Decreased carotid pulses
  • B. Altered level of consciousness
  • C. Bleeding from oral cavity
  • D. Absence of deep tendon-reflexes
Correct Answer: B

Rationale: The correct answer is B: Altered level of consciousness. This is crucial as it can indicate various underlying health issues affecting Mr. Reyes. Assessing for this helps in detecting potential neurological, metabolic, or cardiac issues.

A: Decreased carotid pulses - While important, it is not as critical as altered level of consciousness in this scenario.
C: Bleeding from oral cavity - This is important to address but does not take priority over assessing Mr. Reyes' level of consciousness.
D: Absence of deep tendon-reflexes - This is more specific to neurological assessments and may not be as urgent as assessing his level of consciousness.

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