Nursing Process Test Bank

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A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?

  • A. Make sure he drinks 8 glasses of water a day.
  • B. Monitor for fatigue, muscle weakness, restlessness, and flushed skin
  • C. Look for signs of hyperchloremia
  • D. Observe for neurologic changes
Correct Answer: B

Rationale: The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications.

A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances.
C: Hyperchloremia is not a common concern in this scenario based on the given lab values.
D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.

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Which of the ff. nursing diagnoses is the focus of care for a patient with hypertension?

  • A. Activity intolerance
  • B. Impaired physical mobility
  • C. Ineffective airway clearance
  • D. Deficient knowledge
Correct Answer: D

Rationale: The correct answer is D: Deficient knowledge. This nursing diagnosis is appropriate because educating the patient about hypertension, its management, lifestyle modifications, and medication adherence is crucial in improving outcomes. Activity intolerance (A) and impaired physical mobility (B) are not typically primary focuses for hypertension but may be secondary concerns. Ineffective airway clearance (C) is unrelated to hypertension. Therefore, D is the most relevant option for addressing the patient's needs.

A patient was rushed to the ER because of difficulty in urination. He was diagnosed then as a cse of benign prostate hyperthropy (BPH) and was advised by the doctor to undego transurethral resection of prostate (TURP). Based on the urgency of the surgery, the nurse classifies this condition as:

  • A. emergency
  • B. C.urgent
  • C. elective
  • D. required
Correct Answer: A

Rationale: The correct answer is A: emergency. In this scenario, the patient is experiencing difficulty in urination due to benign prostate hyperplasia (BPH), a condition that can lead to serious complications like acute urinary retention. Transurethral resection of the prostate (TURP) is a surgical procedure that is used to relieve the obstruction caused by BPH. Given the urgency of the situation and the potential for acute complications, the surgery needs to be performed immediately to prevent further harm to the patient's health. Classifying this condition as an emergency ensures prompt intervention and prioritizes the patient's well-being.

Summary:
- B: C.urgent (not correct): While the surgery is time-sensitive, it does not require immediate intervention like in an emergency situation.
- C: elective (not correct): Elective surgeries are planned in advance and are not typically performed in urgent situations like this one.
- D: required (not correct): While the surgery is necessary for the patient's condition

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 nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?

  • A. The patient’s room with the door closed
  • B. The waiting area with the television turned off
  • C. The patient’s room before administration of pain medication
  • D. The waiting room while the occupational therapist is working on leg exercises
Correct Answer: B

Rationale: The correct answer is B: The waiting area with the television turned off. This setting provides a quiet environment, minimizing distractions for the patient with a hearing deficit. It allows the nurse to communicate effectively by speaking clearly and facing the patient directly. Option A is incorrect because a closed door may not be enough to reduce background noise. Option C is incorrect as pain medication may affect the patient's ability to concentrate. Option D is incorrect because the occupational therapist working on leg exercises may create additional noise and distractions.

Seven girls were victims of food poisoning after eating the sandwiches served at snack time. Which of the following statement are true regarding food poisoning?

  • A. Symptoms include salivation, cramping, nausea, vomiting and diarrhea
  • B. Foods that are handled and allowed to remain without refrigeration before eaten are most dangerous
  • C. Cooking will destroy the organism and stop production of enterotoxin
  • D. All are correct
Correct Answer: D

Rationale: Step 1: Symptoms of food poisoning typically include salivation, cramping, nausea, vomiting, and diarrhea, so statement A is correct.
Step 2: Food left unrefrigerated can lead to bacterial growth, making it more dangerous, so statement B is accurate.
Step 3: Cooking can kill harmful organisms and stop the production of toxins, supporting statement C.
Step 4: All three statements are true and collectively provide a comprehensive understanding of food poisoning, making option D the correct answer.

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