Nursing Process Final Exam Questions

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A client was brought to the school clinic wuth severe, constant, localized abdominal pain. Abdominal muscles are rigid, and rebound tenderness is present. Peritonitis is suspected. The client is hypotensive and tachycardic. The nursing diagnosis most appropriate to the client’s signs/symptoms is:

  • A. fluid volume deficit related to depletion of intravascular volume
  • B. altered thought process related to toxic effects of elevated ammonia levels
  • C. abdominal pain related to increased intestinal peristalsis
  • D. altered nutrition: less than body requirements related to malabsorption
Correct Answer: A

Rationale: The correct answer is A: fluid volume deficit related to depletion of intravascular volume. Peritonitis causes inflammation of the peritoneum, leading to fluid shifting into the peritoneal cavity, causing hypovolemia. Hypotension and tachycardia are signs of decreased intravascular volume. Rigid abdominal muscles and rebound tenderness indicate peritoneal irritation. Choice B is incorrect because elevated ammonia levels are not associated with the client's symptoms. Choice C is incorrect because increased peristalsis does not explain the client's hypotension and tachycardia. Choice D is incorrect because malabsorption does not align with the client's acute presentation of severe abdominal pain and peritonitis.

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During a breast examination, which finding most strongly suggests that the client has breast cancer?

  • A. Slight asymmetry of the breasts
  • B. A fixed nodular mass with dimpling of the overlying skin
  • C. Bloody discharge from the nipple
  • D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B

Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is a classic sign of breast cancer. This finding is concerning as it indicates an abnormal growth that has invaded surrounding tissues. Dimpling occurs due to fibrotic changes pulling on the skin. Choices A, C, and D are incorrect. A slight asymmetry of the breasts is common and not necessarily indicative of cancer. Bloody discharge from the nipple can be a sign of other conditions like intraductal papilloma. Multiple firm, round, freely movable masses that change with the menstrual cycle are likely benign fibrocystic changes.

A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?

  • A. Begin with introductions.
  • B. Ask about the chief concerns or problems.
  • C. Explain that the interview will be over in a few minutes.
  • D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:

Rationale: Correct Answer: B: Ask about the chief concerns or problems.

Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to focus the interview on the patient's needs. This step helps in gathering important information and establishing rapport. Introductions are usually done at the beginning of the interview, so it is not the next step. Explaining that the interview will be over in a few minutes can create anxiety and hinder open communication. Telling the patient about administering medications in 1 hour is not relevant at this point in the interview.

A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?

  • A. Begin with introductions.
  • B. Ask about the chief concerns or problems.
  • C. Explain that the interview will be over in a few minutes.
  • D. Tell the patient “I will be back to administer medications in 1 hour.”
Correct Answer:

Rationale: Correct Answer: B: Ask about the chief concerns or problems.

Rationale:
1. Asking about chief concerns helps to focus the interview on the patient's needs.
2. It demonstrates active listening and empathy.
3. Allows the nurse to prioritize issues and provide appropriate care.
4. Introductions are already done, and ending the interview abruptly or mentioning medication timing is not patient-centered.

The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketonic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

  • A. Elevated serum acetone level
  • B. Serum alkalosis
  • C. Serum ketone bodies
  • D. Below-normal serum potassium level
Correct Answer: D

Rationale: Step 1: In HHNS, there is severe hyperglycemia leading to osmotic diuresis.
Step 2: Osmotic diuresis causes loss of potassium in urine, leading to hypokalemia.
Step 3: Hypokalemia is a common electrolyte imbalance in HHNS due to excessive urinary loss of potassium.
Step 4: Therefore, the nurse should anticipate a below-normal serum potassium level in a client with HHNS.

Summary:
A: Elevated serum acetone level is seen in diabetic ketoacidosis, not HHNS.
B: Serum alkalosis is not typically associated with HHNS.
C: Serum ketone bodies are elevated in diabetic ketoacidosis, not HHNS.

Which of the ff. safety instructions should the nurse give a patient who has temporarily dilated pupils?

  • A. Keep eyes closed
  • B. Wear sunglasses
  • C. Do not drive for 8 hours
  • D. Avoid caffeinated beverages
Correct Answer: B

Rationale: The correct answer is B: Wear sunglasses. Dilated pupils are sensitive to light, so wearing sunglasses can help protect the eyes from excessive light exposure. Keeping the eyes closed (A) may provide temporary relief but does not protect the eyes from light. Avoiding driving for 8 hours (C) is important after certain eye procedures but not specifically related to dilated pupils. Avoiding caffeinated beverages (D) is unrelated to pupil dilation.

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