Nursing Process 1 Test Questions

Nursing Process 1 Test Questions Related

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A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?

  • A. Posttrauma syndrome
  • B. Constipation
  • C. Acute pain
  • D. Anxiety
Correct Answer: C

Rationale: The most pertinent nursing diagnosis for the patient with a right femur fracture stabilized in a full leg cast is "Acute pain" (Choice C). The rationale for this is as follows:
1. The patient is experiencing moderate discomfort due to the fracture and immobilization in the cast, indicating a need for pain management.
2. Acute pain is a priority in this situation as it can impact the patient's comfort, mobility, and overall recovery.
3. Managing pain effectively is crucial for promoting healing, preventing complications, and improving the patient's quality of life.
4. Posttrauma syndrome (Choice A) may be a consideration in the long term but is not the immediate priority. Constipation (Choice B) is not the most pertinent nursing diagnosis in this scenario. Anxiety (Choice D) may be present but addressing pain is more urgent and directly related to the patient's current condition.

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A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation?

  • A. Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward.
  • B. Encourage the novice nurse to develop his or her own tool for data collection.
  • C. Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation.
  • D. Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.
Correct Answer: A

Rationale: The correct answer is A because it encourages the novice nurse to independently observe the situation with a peer, validate the data, and discuss afterward. This approach promotes reflection, peer learning, and validation of collected data, which are essential for learning and growth. It allows the nurse to self-assess and correct errors through discussion and feedback.

Choice B is incorrect as it does not address the need for validation and peer feedback. Choice C is incorrect as repeating the same mistake without guidance does not promote learning. Choice D is incorrect as meeting with the nurse manager may not provide the same level of peer learning and validation as observing with a peer.

A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [retrovir]), 200mg PO every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?

  • A. “Take zidovudine with meals.”
  • B. “Take zidovudine on an empty stomach.”
  • C. “Take zidovudine every 4 hours around the clock.”
  • D. “Take over-the-counter(OTC) drugs to treat minor adverse reactions.”
Correct Answer: C

Rationale: The correct answer is C: "Take zidovudine every 4 hours around the clock." Zidovudine is an antiretroviral medication used to treat HIV/AIDS. It is crucial for the client to adhere to the prescribed dosing schedule to maintain therapeutic blood levels. Taking the medication every 4 hours around the clock helps to ensure consistent levels in the body, maximizing its efficacy. Taking it with meals (choice A) or on an empty stomach (choice B) is not specifically indicated for zidovudine. Choice D is incorrect as taking OTC drugs without consulting a healthcare provider can lead to drug interactions or adverse effects. Hence, choice C is the most appropriate instruction to ensure the client benefits from the medication.

A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?

  • A. Posttrauma syndrome
  • B. Constipation
  • C. Acute pain
  • D. Anxiety
Correct Answer: C

Rationale: The correct answer is C: Acute pain. This is the most pertinent nursing diagnosis because the patient has a right femur fracture and reports moderate discomfort. The priority is to address the acute pain associated with the fracture. Posttrauma syndrome (A) typically involves a broader range of emotional and psychological responses beyond just moderate discomfort. Constipation (B) is not the priority in this case, as it is not directly related to the patient's current condition. Anxiety (D) may be present but addressing the acute pain takes precedence in this situation to ensure the patient's comfort and well-being.

A client, age 42, visits the gynecologist. After examining her, the physician suspects cervical cancer. The nurse reviews the client’s history for risk factors for this disease. Which history finding is a risk factor for cervical cancer?

  • A. Onset of sporadic sexual activity at age 17
  • B. Pregnancy complicated with eclampsia at
  • C. Spontaneous abortion at age 19 age 27
  • D. Human papilloma virus infection at age 32
Correct Answer: D

Rationale: The correct answer is D: Human papilloma virus (HPV) infection at age 32. HPV is a known risk factor for cervical cancer as it can lead to cellular changes in the cervix. Here's the rationale:
1. HPV is a sexually transmitted infection that can cause abnormal cell growth in the cervix.
2. Persistent HPV infection is a major risk factor for developing cervical cancer.
3. Age 32 is within the typical age range for HPV infection and the development of cervical cancer.
4. Choices A, B, and C are unrelated to the primary risk factor for cervical cancer, which is HPV infection.

A nurse teaches a client newly diagnosed with diabetes how to administer insulin. What type of nursing intervention is this?

  • A. Independent intervention
  • B. Dependent intervention
  • C. Interdependent intervention
  • D. Collaborative intervention
Correct Answer: A

Rationale: Correct Answer: A (Independent intervention)

Rationale:
1. Independent interventions are actions that nurses can initiate without a doctor's order.
2. Teaching a client how to administer insulin falls under the scope of nursing practice.
3. Nurses have the knowledge and authority to educate clients on self-care management.
4. This intervention does not require collaboration with other healthcare providers.

Summary:
B: Dependent interventions require a doctor's order.
C: Interdependent interventions involve collaboration with other healthcare providers.
D: Collaborative interventions involve working with other healthcare professionals.

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