Nursing Process Exam Questions

Nursing Process Exam Questions Related

Review Nursing Process Exam Questions related questions and content

A 90 y.o. nursing home resident with stage 2 Alzheimer’s disease is found alone and crying in the dining room. She says she lost her mother and doesn’t know what to do. Which response by the nurse will help calm the resident?

  • A. “Remember your mother has been dead for 30 years. You forgot again, didn’t you?”
  • B. “I’m sorry you lost your mother; let’s go and try to find her.”
  • C. “Are you feeling frightened? I’m here and I will help you.”
  • D. “You are 90 years old. It is impossible for your mother to still be living. I know if you try, you can figure out what to do.”
Correct Answer: C

Rationale: The correct answer is C: “Are you feeling frightened? I’m here and I will help you.” This response acknowledges the resident’s feelings, offers reassurance, and provides support, focusing on the resident's emotional needs rather than the accuracy of her statements. It shows empathy and validation of her feelings, which can help calm the resident and build trust.

Choice A is incorrect because it dismisses the resident's feelings and reality, which can lead to increased distress and confusion. Choice B is incorrect as it doesn't address the resident's emotional state or offer immediate support. Choice D is incorrect as it focuses on correcting the resident's perception rather than providing emotional support, which may lead to further distress.

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A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?

  • A. It’s normal and requires no action
  • B. It calls for a repeat Pap test in 6 weeks
  • C. It calls for a repeat Pap test in 3 months
  • D. It calls for a biopsy as soon as possible
Correct Answer: D

Rationale: The correct answer is D because a class V finding on a Pap test indicates severe dysplasia or carcinoma in situ, which requires further evaluation through a biopsy to confirm the presence of abnormal cells. This finding is not normal and necessitates immediate action for diagnosis and potential treatment. Choices A, B, and C are incorrect because they do not address the urgency and seriousness of a class V finding, which mandates prompt follow-up to rule out or confirm the presence of precancerous or cancerous cells.

An elderly patient, Mr. Cruz is being cared for by nurse Bennie because of pulmonary embolism. Nurse Bennie would anticipate an order for immediate administration of:

  • A. warfarin
  • B. heparin
  • C. dexamethazone
  • D. protamine sulfate
Correct Answer: B

Rationale: The correct answer is B: heparin. Heparin is an anticoagulant used for immediate treatment of pulmonary embolism to prevent further clot formation. It acts quickly by inhibiting clotting factors. Warfarin (A) is used for long-term anticoagulation but has a slower onset. Dexamethasone (C) is a corticosteroid used for inflammation, not thrombosis. Protamine sulfate (D) is used to reverse the effects of heparin but is not indicated for initial treatment.

The nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:

  • A. increasing saturated fat intake and fasting in the afternoon.
  • B. increasing intake of vitamins B and D and taking iron supplements.
  • C. eating a candy bar if light-headedness occurs.
  • D. consuming a low-carbohydrate, high-protein diet and avoiding fasting.
Correct Answer: D

Rationale: The correct answer is D because a low-carbohydrate, high-protein diet helps stabilize blood sugar levels and prevents hypoglycemic episodes. Carbohydrates cause rapid spikes and drops in blood sugar, while protein helps maintain stable levels. Avoiding fasting also helps regulate blood sugar. Choice A is incorrect as increasing saturated fat and fasting can worsen hypoglycemia. Choice B is incorrect as vitamins and iron do not directly address hypoglycemia. Choice C is incorrect as relying on sugary foods like candy bars can lead to further blood sugar imbalances.

A 19 y.o. student develops trigeminal neuralgia. Which of the ff. actions will most likely aggravate her pain?

  • A. Sleeping
  • B. Reading
  • C. Eating
  • D. Cooking
Correct Answer: C

Rationale: The correct answer is C: Eating. Chewing food can trigger trigeminal nerve pain due to the movement and pressure applied on the nerve. The other choices (A: Sleeping, B: Reading, D: Cooking) do not involve the same level of jaw movement and pressure on the trigeminal nerve, thus are less likely to aggravate the pain. Therefore, eating is the most likely action to worsen trigeminal neuralgia symptoms in this scenario.

An elderly nursing home resident who has always been alert and oriented is now showing signs of dehydration and has become confused. Which electrolyte imbalance is most likely involved?

  • A. Hyponatremia
  • B. Hypercalcemia
  • C. Hyperkalemia
  • D. Hypomagnesemia
Correct Answer: D

Rationale: The correct answer is D: Hypomagnesemia. Dehydration can lead to electrolyte imbalances, and hypomagnesemia can cause confusion in elderly patients. Magnesium plays a crucial role in brain function and its deficiency can result in cognitive impairment. Hyponatremia (A) typically presents with symptoms like weakness and confusion but not necessarily dehydration. Hypercalcemia (B) and hyperkalemia (C) are less likely to cause confusion in this scenario. Therefore, hypomagnesemia is the most likely electrolyte imbalance involved in the elderly nursing home resident's confusion.

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