Nursing Process Final Exam Questions

Nursing Process Final Exam Questions Related

Review Nursing Process Final Exam Questions related questions and content

A patient visiting with family members in the waiting area tells the nurse “I don’t feel good, especially in the stomach.” What should the nurse do?

  • A. Request that the family leave, so the patient can rest.
  • B. Ask the patient to return to the room, so the nurse can inspect the abdomen.
  • C. Ask the patient when the last bowel movement was and to lie down on the sofa. Tell the patient that the dinner tray will be ready in 15 minutes and that may help
  • D. the stomach feel better.
Correct Answer: B

Rationale: The correct answer is B: Ask the patient to return to the room, so the nurse can inspect the abdomen.

Rationale:
1. Patient safety: By examining the patient's abdomen, the nurse can assess for any signs of distress or potential medical issues.
2. Patient-centered care: It is essential to prioritize the patient's well-being by addressing their concerns promptly and appropriately.
3. Professional responsibility: Nurses are trained to assess and evaluate patient symptoms to provide necessary care and support.

Summary:
A: Requesting the family to leave does not address the patient's symptoms and may disrupt the patient's support system.
C: Asking about bowel movements and offering food may not be appropriate if the patient is experiencing stomach discomfort.
D: Offering food without proper assessment may worsen the patient's condition and is not recommended before a proper evaluation.

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The nurse is aware that multiple sclerosis is a progressive disease of the central nervous system characterized by:

  • A. Axon degeneration
  • B. Sclerosed patches of nervous system
  • C. Demyelination of the brain and spinal cord
  • D. All of the above
Correct Answer: D

Rationale: Step 1: Multiple sclerosis (MS) is a progressive disease affecting the central nervous system.
Step 2: Axon degeneration occurs in MS, leading to impaired nerve signal transmission.
Step 3: MS is characterized by sclerosed patches, or plaques, in the nervous system.
Step 4: Demyelination of the brain and spinal cord is a hallmark feature of MS.
Step 5: Therefore, all of the above choices are correct as they accurately describe key features of MS.

JR is admitted to the medical-surgical unit because of a diagnosis of nephritic syndrome. What is the hallmark of this syndrome?

  • A. osmotic dieresis
  • B. hypolipidemia
  • C. edema
  • D. hyperproteinemia
Correct Answer: C

Rationale: The hallmark of nephritic syndrome is edema due to proteinuria leading to hypoalbuminemia. Protein loss in urine causes decreased colloid osmotic pressure, leading to fluid leaking into tissues, causing edema. Osmotic diuresis (A) is unrelated to nephritic syndrome. Hypolipidemia (B) and hyperproteinemia (D) are not characteristic of nephritic syndrome.

Which of the following is most important discharge teaching for Mr. Dela Isla

  • A. Emergency Numbers
  • B. Relaxation technique
  • C. Drug Compliance
  • D. Dietary prescription SITUATION: Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Correct Answer: C

Rationale: The correct answer is C: Drug Compliance. After a CVA (stroke), it is crucial for Mr. Dela Isla to understand and adhere to his prescribed medications. Medications help prevent further strokes and manage underlying conditions. Drug compliance ensures optimal treatment outcomes. Emergency Numbers (A) are important but not the priority post-stroke. Relaxation techniques (B) may be helpful but not as critical as medication adherence. Dietary prescription (D) is important but not as urgent as drug compliance in this scenario.

A patient reports on admission being “very sick” after taking erythromycin in the past. The patient is to receive erythromycin now. Which of the following actions should the nurse take regarding giving the antibiotic?

  • A. Give the antibiotic
  • B. Do not give the antibiotic
  • C. Give half of the dose
  • D. Discontinue the antibiotic
Correct Answer: B

Rationale: The correct answer is B: Do not give the antibiotic. This is because the patient has a history of being "very sick" after taking erythromycin in the past, indicating a potential allergic reaction or severe adverse effects. The nurse should not administer the antibiotic to prevent harm to the patient. Choice A is incorrect as it can lead to a repeat adverse reaction. Choice C, giving half the dose, still exposes the patient to potential harm. Choice D, discontinuing the antibiotic, is also incorrect as it implies the patient has already started the medication, which should not be the case given the history of adverse effects.

A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which of the following suggests that the decongestant has been effective?

  • A. Increased salivation
  • B. Reduced sneezing
  • C. Increased tearing
  • D. Headache
Correct Answer: B

Rationale: The correct answer is B: Reduced sneezing. Decongestants work by constricting blood vessels in the nasal passages, reducing swelling and congestion, which in turn can lead to a decrease in sneezing. Increased salivation (choice A) is not a typical effect of decongestants. Increased tearing (choice C) is more commonly associated with allergies or irritants. Headache (choice D) can be a side effect of decongestants due to their impact on blood vessels, but it does not necessarily indicate effectiveness in treating allergic rhinitis.

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