Nursing Process Practice Questions

Nursing Process Practice Questions Related

Review Nursing Process Practice Questions related questions and content

A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?

  • A. Anticipatory grieving
  • B. Disturbed body image
  • C. Impaired swallowing
  • D. Chronic low self-esteem
Correct Answer: A

Rationale: The correct answer is A: Anticipatory grieving. This nursing diagnosis is appropriate because the client's symptoms, such as weight loss, fatigue, and diagnosis of gallbladder cancer, indicate a serious health condition that may lead to emotional distress. Anticipatory grieving involves feelings of loss and sadness related to an anticipated loss, such as the diagnosis of cancer. The client may experience fear, anxiety, and sadness due to the potential impact of the illness on their life.

Choice B (Disturbed body image) is incorrect because the client's symptoms are more indicative of a serious health concern rather than body image issues. Choice C (Impaired swallowing) is incorrect as the symptoms described do not suggest difficulty with swallowing. Choice D (Chronic low self-esteem) is also incorrect as the symptoms are more likely related to physical health issues rather than self-esteem concerns.

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A client becomes upset when the physician diagnoses diabetes mellitus as the cause of current signs and symptoms. The client tells the nurse, “This must be a mistake. No one in my family has ever had diabetes.” Based on this statement, the nurse suspects the client is using which coping mechanism?

  • A. Denial
  • B. Anger
  • C. Withdrawal
  • D. Resolution
Correct Answer: A

Rationale: The correct answer is A: Denial. The client's refusal to accept the diagnosis of diabetes mellitus, stating that no one in their family has had it, indicates denial as a coping mechanism. Denial is a defense mechanism where individuals refuse to acknowledge unpleasant realities. In this case, the client is rejecting the diagnosis to avoid facing the reality of having a chronic condition. The other choices (B: Anger, C: Withdrawal, D: Resolution) do not fit the client's response in this scenario. Anger involves expressing frustration or hostility, withdrawal is avoiding the situation, and resolution is accepting and dealing with the issue.

A client in the final stages of terminal cancer tells the nurse: “I wish I could be just be allowed to die. I’m tired of fighting this illness. I have lived life a good life. I only continue my chemotherapy and radiation treatment because my family wants me to.” What is the best nurse’s best response?

  • A. “Would you like to talk to a psychologist about your thoughts and feelings?”
  • B. “Would you like to talk to your minister about the significance of death?”
  • C. “Would you like to meet with your family and your physician about this matter?”
  • D. “I know you are tired of fighting this illness, but death will come in due time.”
Correct Answer: C

Rationale: The correct response is C: “Would you like to meet with your family and your physician about this matter?”

Rationale:
1. Involving the family and physician ensures a collaborative decision-making process.
2. It respects the client's autonomy and involves them in the decision-making process.
3. It promotes open communication and support from loved ones.
4. It addresses the client's concerns about continuing treatment based on family wishes.

Summary:
A: Refers to psychological support, but the client's primary concern is medical treatment decisions.
B: Involves religious support, which may not align with the client's beliefs or address the medical decision.
D: Acknowledges the client's feelings but lacks a collaborative approach involving family and healthcare team.

An adult is on a clear liquid diet. Which food item can be offered/

  • A. Milk
  • B. Orange juice
  • C. Jello
  • D. Ice cream
Correct Answer: C

Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids that do not contain any solid particles, providing easily digestible nutrients. Jello meets these criteria as it is a clear, gelatin-based dessert that melts into a liquid form at room temperature.

Rationale:
1. Jello is a clear liquid that does not contain solid particles, making it suitable for a clear liquid diet.
2. Milk (A) and ice cream (D) are not considered clear liquids as they contain fats and proteins, which are not allowed on a clear liquid diet.
3. Orange juice (B) contains pulp and fibers, making it unsuitable for a clear liquid diet.

Summary:
Jello is the correct choice because it meets the criteria of being a clear liquid without solid particles. Milk, orange juice, and ice cream are not appropriate choices for a clear liquid diet due to their composition.

The nurse is caring for a client in the emergency room diagnosed with Bell’s palsy. The client has been taking acetaminophen (Tylenol), and acetaminophen overdose is suspected. The nurse anticipates that the antidote to be prescribed is:

  • A. Pentostatin (Nipent)
  • B. Fludarabine (Fludara)
  • C. Auranofin (Ridaura)
  • D. Acetylcysteine Mucomyst)
Correct Answer: D

Rationale: Rationale: Acetylcysteine (Mucomyst) is the antidote for acetaminophen overdose. It works by replenishing glutathione, which helps neutralize the toxic metabolite of acetaminophen. Pentostatin, Fludarabine, and Auranofin are not antidotes for acetaminophen overdose and are used for different conditions. Acetylcysteine is the correct choice as it directly counteracts the toxic effects of acetaminophen.

Choose the condition th₃a⁻t exhibits blood values with a low pH and a low plasma bicarbonate concentration:

  • A. Respiratory acidosis
  • B. Metabolic acidosis
  • C. Respiratory alkalosis
  • D. Metabolic alkalosis
Correct Answer: B

Rationale: Step-by-step rationale:
1. Metabolic acidosis is characterized by low pH and low plasma bicarbonate.
2. In this condition, there is an excess of acids or a loss of bicarbonate.
3. The kidneys are unable to adequately excrete acids or retain bicarbonate.
4. This leads to a decrease in bicarbonate levels and a decrease in pH.
5. Respiratory acidosis (A) is characterized by low pH and high CO2 levels.
6. Respiratory alkalosis (C) is characterized by high pH and low CO2 levels.
7. Metabolic alkalosis (D) is characterized by high pH and high bicarbonate levels.

Summary:
- Choice A is incorrect as it describes a condition with high CO2 levels.
- Choice C is incorrect as it describes a condition with high pH.
- Choice D is incorrect as it describes a condition with high bicarbonate levels.
- Choice B is correct as it accurately describes the characteristics of a condition with low pH

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