Nursing Process Practice Questions

Nursing Process Practice Questions Related

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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.

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A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

  • A. Ambulating a patient
  • B. Inserting a feeding tube
  • C. Performing resuscitation
  • D. Documenting wound care
Correct Answer: A

Rationale: The correct answer is A: Ambulating a patient. Direct care interventions involve hands-on activities directly impacting patient outcomes. Ambulating a patient is a direct care intervention as it involves physically assisting the patient to move, promoting circulation, preventing complications, and improving overall well-being. Inserting a feeding tube (B) and performing resuscitation (C) are also direct care interventions as they involve immediate patient care actions. Documenting wound care (D) is not a direct care intervention as it involves recording information about a care activity rather than physically performing the care itself.

The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body’s normal flora, the nurse must monitor the client for:

  • A. Platelet dysfunction
  • B. Stomatitis
  • C. Oliguria and dysuria
  • D. Diarrhea
Correct Answer: D

Rationale: The correct answer is D: Diarrhea. Antibiotics can disrupt the normal balance of gut bacteria, leading to diarrhea. This occurs due to the overgrowth of harmful bacteria in the intestines. Monitoring for diarrhea is crucial to prevent dehydration and further complications. Platelet dysfunction (A), stomatitis (B), and oliguria/dysuria (C) are not typically associated with the disruption of normal flora by antibiotics. These symptoms are more likely related to other conditions or side effects of medications, making them incorrect choices in this scenario.

The nurse is teaching a patient newly diagnosed with AIDS about complications of the disease. Which of the following is the most common opportunistic infection in AIDS?

  • A. Pneumocystis carinii pneumonia
  • B. Toxoplasmosis
  • C. Candidiasis
  • D. Mycoplasma pneumoniae
Correct Answer: A

Rationale: The correct answer is A: Pneumocystis carinii pneumonia (PCP). PCP is the most common opportunistic infection in AIDS due to the weakened immune system, making patients vulnerable to this fungal infection. PCP is a leading cause of morbidity and mortality in AIDS patients. Toxoplasmosis (B) is also common but not as prevalent as PCP in AIDS. Candidiasis (C) is a common fungal infection but not the most common in AIDS. Mycoplasma pneumoniae (D) is a bacterial infection and not typically considered an opportunistic infection in AIDS.

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: Rationale: Parkinson's disease is characterized by dopamine deficiency in the brain, leading to motor symptoms like bradykinesia, rigidity, and tremors. Dopamine is crucial for controlling movement. Acetylcholine (A) is not directly related to Parkinson's symptoms. Serotonin (B) is involved in mood regulation, not movement control. Phenylalanine (D) is an amino acid and not directly related to Parkinson's pathology. Therefore, the correct answer is C.

The nurse knows which of the following is true about immunity?

  • A. Antibody-mediated defense occurs through the T-cell system
  • B. Cellular immunity is mediated by antibodies produced by the B-cells
  • C. Antibodies are produced by the B-cells
  • D. Lymphocytes increase with an allergic response
Correct Answer: C

Rationale: Rationale:
Choice C is correct because antibodies are indeed produced by B-cells as part of the adaptive immune response. B-cells differentiate into plasma cells that produce antibodies to target specific antigens. This process is essential for generating immunity against pathogens.

Incorrect Choices:
A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity.
B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. T-cells directly attack infected cells.
D: Lymphocytes can increase during an allergic response, but this does not specifically relate to immunity through antibody production by B-cells.

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