Nursing Process Questions

Nursing Process Questions Related

Review Nursing Process Questions related questions and content

A client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer?

  • A. Persistent nausea
  • B. Indigestion
  • C. Rash
  • D. Chronic ache or pain
Correct Answer: D

Rationale: The correct answer is D: Chronic ache or pain. Persistent cough and chronic ache or pain are both common warning signs of cancer. Chronic pain can be a symptom of various types of cancer, signaling the presence of a tumor or cancerous growth. It is important for the client to seek medical evaluation to rule out any underlying serious condition.

A: Persistent nausea is not typically considered a common warning sign of cancer. While it can be a symptom in certain types of cancer or due to treatment side effects, it is not as prominent as chronic ache or pain.

B: Indigestion is a common symptom that can be caused by various non-cancer-related issues such as dietary habits, stress, or gastrointestinal disorders. It is not typically considered a direct warning sign of cancer.

C: Rash is generally not a common warning sign of cancer. Rashes are more commonly associated with skin conditions, allergic reactions, or infections rather than being an indicator of cancer.

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A patient’s serum sodium is within normal range. The nurse estimates that serum osmolality should be:

  • A. Less than 136mOsm/kg
  • B. Greater than 408mOsm/kg
  • C. 280 to 295mOsm/kg
  • D. 350 to 544mOsm/kg
Correct Answer: C

Rationale: The correct answer is C (280 to 295mOsm/kg) because serum osmolality is primarily determined by sodium, glucose, and blood urea nitrogen levels. Normal serum sodium range is 135-145 mEq/L, which corresponds to an osmolality range of 280-295 mOsm/kg. Choices A and B are incorrect as they do not align with normal serum sodium levels. Choice D is incorrect as it includes an excessively wide range that is not consistent with normal osmolality values.

A client diagnosed with DIC is ordered heparin. What is the reason for this medication?

  • A. Prevent clot formation
  • B. Increase clot formation
  • C. Increased blood flow to target organs
  • D. Decrease blood flow to target organs
Correct Answer: A

Rationale: The correct answer is A: Prevent clot formation. Heparin is an anticoagulant that inhibits the formation of blood clots. In DIC (Disseminated Intravascular Coagulation), there is excessive clotting throughout the body, leading to organ damage. By administering heparin, we aim to prevent further clot formation and reduce the risk of complications.

Choice B is incorrect because heparin does not increase clot formation; it works to inhibit clotting. Choice C is incorrect as heparin does not directly increase blood flow to target organs. Choice D is also incorrect as heparin does not decrease blood flow to target organs; its primary role is anticoagulation.

Nurse Kara is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?

  • A. wear comfortable shoes that fit well and protect your feet
  • B. trim your toenails straight across and file edges with emery board
  • C. wash your feet in hot water to keep feet soft
  • D. wear shoes at the beach or on hot pavement
Correct Answer: C

Rationale: The correct answer is C. Washing feet in hot water is not part of diabetic foot care as it can lead to burns or skin damage. A: Properly fitting shoes help prevent injuries. B: Trimming toenails straight reduces risk of ingrown nails. D: Wearing shoes on hot surfaces protects feet from burns or injuries. Overall, C is incorrect due to its potential harm to the client's feet.

Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:

  • A. A genetic defect in the production of acetylcholine
  • B. A reduced amount of neurotransmitter acetylcholine
  • C. A decreased number of functioning acetyl-choline receptor sites
  • D. An inhibition of the enzyme Ache leaving the end plates folded.
Correct Answer: C

Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease.

Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites. Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites. Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.

Which of the following explanations by the nurse will help a patient understand what to expect during a bronchoscopy?

  • A. “The physician will place a small tube through your nose or mouth and into the bronchi to look at your airways.”
  • B. “You will breathe a radioactive substance that will show diseased areas in your lungs.”
  • C. “You will need to drink a thick white liquid, which will be opaque on the x-rays.”
  • D. “A die will be injected to help visualize the structures of the bronchioles. Do you have any allergies?”
Correct Answer: A

Rationale: The correct answer is A because it accurately describes the procedure of bronchoscopy. The nurse's explanation should focus on the insertion of a small tube through the nose or mouth into the bronchi to visualize the airways. This information helps the patient understand the basic process and what to expect during the procedure.

Choice B is incorrect as bronchoscopy does not involve breathing a radioactive substance to show diseased areas in the lungs. Choice C is also incorrect as there is no requirement to drink a thick white liquid for bronchoscopy. Choice D is incorrect as dye injection is not a standard part of bronchoscopy, and asking about allergies to dye is irrelevant in this context.

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