Nursing Process Questions and Answers PDF

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A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo- oopherectomy with tumor secretion, omentectomy, appendectomy, and lymphadenopathy. During the second postoperative day, which of the following assessment findings would raise concern in the nurse?

  • A. Abdominal pain
  • B. Serous drainage from the incision
  • C. Hypoactive bowel sounds
  • D. Shallow breathing and increasing lethargy
Correct Answer: D

Rationale: The correct answer is D: Shallow breathing and increasing lethargy. This finding could indicate a potential respiratory complication such as atelectasis or pneumonia, which are common postoperative complications. Shallow breathing can lead to inadequate oxygenation and ventilation, causing lethargy due to decreased oxygen delivery to tissues. It is crucial to assess and address respiratory issues promptly to prevent further complications.

A: Abdominal pain is expected postoperatively and can be managed with pain medications.
B: Serous drainage from the incision is a normal finding after surgery and indicates the wound is healing properly.
C: Hypoactive bowel sounds are common after surgery due to decreased peristalsis and can be managed with interventions such as early ambulation and medications.

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An agitated, confused client arrives in the emergency department. The client’s history includes type 1 diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:

  • A. 2 to 5 of a simple carbohydrate.
  • B. 18 to 20 g of a simple carbohydrat
  • C. 10 to 15 g of a simple carbohydrate.
  • D. 25 to 30 g of a simple carbohydrate.
Correct Answer: C

Rationale: The correct answer is C: 10 to 15 g of a simple carbohydrate. This amount of carbohydrate is recommended for treating hypoglycemia in clients with diabetes to quickly raise blood glucose levels without causing hyperglycemia. Consuming too little carbohydrate may not effectively raise blood glucose levels, while consuming too much may lead to a rapid spike followed by a rebound hypoglycemia. Options A and B provide insufficient amounts of carbohydrate, while option D provides excessive carbohydrate, increasing the risk of hyperglycemia. Therefore, option C is the most appropriate choice for effectively treating hypoglycemia in this client.

A 58-year-old man is diagnosed with cancer of the larynx. Which of the ff. are early symptoms of this cancer?

  • A. Anemia and fatigue
  • B. A noticeable lump in the neck
  • C. Crackles and stridor
  • D. Dysphagia or hoarseness
Correct Answer: D

Rationale: The correct answer is D: Dysphagia or hoarseness. In laryngeal cancer, dysphagia and hoarseness are early symptoms due to vocal cord involvement. Hoarseness results from vocal cord paralysis, while dysphagia occurs when the tumor obstructs the esophagus. Anemia and fatigue (choice A) are nonspecific symptoms seen in various conditions. A noticeable lump in the neck (choice B) typically indicates metastasis to the lymph nodes, which occurs later in laryngeal cancer. Crackles and stridor (choice C) are more associated with respiratory conditions rather than laryngeal cancer.

According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?

  • A. Ineffective airway clearance
  • B. Ineffective coping
  • C. Impaired urinary elimination
  • D. Risk for body image disturbance
Correct Answer: D

Rationale: The correct answer is D: Risk for body image disturbance. In the context of Maslow's hierarchy of needs, physiological needs take precedence over psychological needs. For a client in the intensive care unit with congestive heart failure, ensuring physiological needs like airway clearance, urinary elimination, and coping are addressed first is crucial for survival. Body image disturbance is a higher-level psychological need and can be addressed once basic physiological needs are met. Therefore, addressing the risk for body image disturbance would have the lowest priority compared to the other options provided.

If a patient has elevated pulmonary vascular pressures, the nurse understands that the patient is most likely to develop which of the ff. physiological cardiac changes?

  • A. Left atrial atrophy
  • B. Left ventricular hypertrophy
  • C. Right atrial atrophy
  • D. Right ventricular hypertrophy
Correct Answer: D

Rationale: The correct answer is D: Right ventricular hypertrophy. Elevated pulmonary vascular pressures lead to increased resistance in the pulmonary circulation, causing the right ventricle to work harder to pump blood to the lungs. Over time, this can result in hypertrophy of the right ventricle as it adapts to the increased workload. Left atrial atrophy (A) and right atrial atrophy (C) are unlikely as the atria are not directly affected by elevated pulmonary pressures. Left ventricular hypertrophy (B) is not the correct choice as it typically occurs in response to systemic hypertension, not pulmonary hypertension.

Mr. RR is to have a brain scanning. Nursing intervention in preparation for this test includes:

  • A. Discontinuing any anticonvulsant therapy
  • B. Obtaining consent for the treatment
  • C. Explaining to Mr. RR that although his head will be supported in place for a period of time, the test will not be painful.
  • D. Informing Mr. RR that nausea and headache are frequent following this test
Correct Answer: C

Rationale: The correct answer is C because it addresses the specific nursing intervention needed to prepare Mr. RR for the brain scanning test. By explaining to Mr. RR that the test will not be painful and that his head will be supported in place, the nurse helps alleviate any potential anxiety or fear he may have. This information reassures the patient and ensures his cooperation during the procedure.

Choice A is incorrect because discontinuing anticonvulsant therapy without medical approval could have serious consequences for Mr. RR's health. Choice B is also incorrect as obtaining consent is important, but it is not directly related to preparing Mr. RR for the test. Choice D is incorrect as it introduces potential negative outcomes without providing necessary information to prepare the patient for the test.

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