Nursing Process Questions

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A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?

  • A. Ineffective breathing pattern related to pneumonia
  • B. Risk for infection related to chest x-ray procedure NursingStoreRN
  • C. Risk for deficient fluid volume related to dehydration
  • D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D

Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates as it directly addresses the underlying physiological issue of impaired gas exchange due to alveolar-capillary membrane changes. The infiltrates indicate infection and inflammation in the lower lobes, leading to difficulty in oxygen and carbon dioxide exchange. This diagnosis aligns with the patient's medical condition and helps guide nursing interventions focused on improving oxygenation.

Choice A is incorrect because ineffective breathing pattern is a broad diagnosis that does not specifically address the gas exchange issue seen in pneumonia. Choice B is incorrect as the risk for infection is already present with the diagnosis of pneumonia and does not directly address the patient's current respiratory status. Choice C is incorrect as dehydration is not the primary concern in a patient with pneumonia and lower lobe infiltrates.

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Which of the following is the humoral immune response?

  • A. B cells phagocytise the foreign antigen
  • B. T cells are stimulated by B cells and turn into plasma cells, which produce antibodies or memory cells.
  • C. B cells are stimulated by T helper cells or macrophages and turn into plasma cells, which produce antibodies or memory cells.
  • D. T cells produce antibodies.
Correct Answer: C

Rationale: The correct answer is C because in the humoral immune response, B cells are stimulated by T helper cells or macrophages to differentiate into plasma cells that produce antibodies or memory cells. This process involves the production of specific antibodies that target the foreign antigen.

Choice A is incorrect because B cells do not phagocytize antigens; instead, they produce antibodies.

Choice B is incorrect because T cells do not turn into plasma cells. It is the B cells that differentiate into plasma cells in the humoral immune response.

Choice D is incorrect because T cells do not produce antibodies. T cells are involved in cell-mediated immunity, not the humoral immune response.

The nurse is caring for a patient with HIV. Which of the following foods would the nurse teach the patient is safe to eat to reduce the risk of infection?

  • A. Raw fruits
  • B. Raw vegetables
  • C. Cooked vegetables
  • D. Caesar dressing
Correct Answer: C

Rationale: The correct answer is C: Cooked vegetables. Cooking vegetables helps to kill harmful bacteria and parasites that may pose a risk of infection to an immunocompromised individual like a patient with HIV. Raw fruits (A) and raw vegetables (B) may carry pathogens that can be dangerous for someone with a weakened immune system. Caesar dressing (D) may contain raw eggs, which also pose a risk for infection. Therefore, choosing cooked vegetables is the safest option to reduce the risk of infection for the patient with HIV.

A client has undergone the Snellen eye chart test and has 20/40 vision. Which of the ff is true for this client?

  • A. The client sees letters at 20 feet that others can read at 40 feet
  • B. The client sees letters at 40 feet that others can read at 20 feet
  • C. The client sees colors at 20 feet that others can see at 40 feet
  • D. The client sees colors at 40 feet that others can see at 20 feet
Correct Answer: A

Rationale: The correct answer is A. In the Snellen eye chart test, the first number (20) represents the distance at which the client is viewing the chart, and the second number (40) represents the distance at which a person with normal vision can read the same line. Therefore, a client with 20/40 vision sees letters at 20 feet that others with normal vision can read at 40 feet.

Choices B, C, and D are incorrect because they do not accurately reflect the interpretation of the 20/40 vision result from the Snellen eye chart test. B is incorrect because the client does not see letters at 40 feet that others can read at 20 feet. Choices C and D are incorrect because the Snellen eye chart test measures visual acuity, not color perception.

A client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?

  • A. Stool hematest
  • B. Abdominal computed tomography (CT)
  • C. Carcinoembryonic antigen (CEA) scan
  • D. Sigmoidoscopy
Correct Answer: D

Rationale: The correct answer is D: Sigmoidoscopy. Sigmoidoscopy is a direct visualization procedure that allows for examination of the lower part of the colon and rectum, where colorectal cancer commonly occurs. This procedure can help identify any abnormal growths or polyps that may indicate cancer. Stool hematest (A) detects blood in stool but does not confirm colorectal cancer. Abdominal CT (B) provides imaging of the abdomen but may not definitively diagnose colorectal cancer. CEA scan (C) measures a tumor marker associated with colorectal cancer but is not a definitive diagnostic test. Thus, sigmoidoscopy is the most appropriate diagnostic study for confirming colorectal cancer.

Nurse Carlos teaches a community adult class about the common symptoms of tuberculosis. Which of the following should Nurse Carlos include?

  • A. weight loss
  • B. dyspnea on exertion
  • C. increased appetite
  • D. mental status changes
Correct Answer: A

Rationale: The correct answer is A: weight loss. Weight loss is a common symptom of tuberculosis due to the impact of the infection on the body's metabolism and appetite. This symptom is important to recognize as it can be an early indicator of the disease. Dyspnea on exertion (B) is not a common symptom of tuberculosis, as it typically affects the lungs rather than causing difficulty breathing. Increased appetite (C) is not a typical symptom, as TB usually leads to decreased appetite and weight loss. Mental status changes (D) are not directly associated with tuberculosis and are more commonly seen in other conditions affecting the brain. Therefore, weight loss is the most relevant symptom to include in the teaching material for identifying possible cases of tuberculosis.

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