Nursing Process Final Exam Questions

Nursing Process Final Exam Questions Related

Review Nursing Process Final Exam Questions related questions and content

A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self- catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?

  • A. Risk
  • B. Problem focused
  • C. Health promotion
  • D. Collaborative problem
Correct Answer: C

Rationale: The correct answer is C: Health promotion. The nurse wrote a diagnosis of Readiness for enhanced urinary elimination, which indicates the patient's willingness to improve their urinary elimination abilities. Health promotion diagnoses focus on improving the client's well-being and enhancing their health potential. In this scenario, the patient's desire to learn self-catheterization aligns with health promotion as it involves empowering the patient to take an active role in their care.

Choice A (Risk) is incorrect because the patient is not currently at risk for urinary elimination issues, but rather seeking to enhance their abilities. Choice B (Problem focused) is incorrect as the diagnosis is not about addressing a current problem but rather focusing on potential improvement. Choice D (Collaborative problem) is incorrect as it does not involve collaboration between healthcare providers but rather focuses on the patient's readiness and willingness to enhance their own health outcomes.

You may also like to solve these questions

The nurse is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?

  • A. 24 hours
  • B. 7 to 14 days
  • C. 2 to 4 days
  • D. 21 to 28 days
Correct Answer: B

Rationale: The correct answer is B: 7 to 14 days. Marrow suppression from floxuridine typically occurs 1-2 weeks after administration due to its effects on rapidly dividing cells in the bone marrow. This is known as the nadir period. Choices A, C, and D are incorrect because 24 hours is too soon for noticeable effects, 2 to 4 days is too short for the nadir period, and 21 to 28 days is too long for the onset of marrow suppression. The correct choice aligns with the expected timeframe for floxuridine's impact on bone marrow function.

During a breast examination, which finding most strongly suggests that the client has breast cancer?

  • A. Slight asymmetry of the breasts
  • B. A fixed nodular mass with dimpling of the overlying skin
  • C. Bloody discharge from the nipple
  • D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B

Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is a classic sign of breast cancer. This finding is concerning as it indicates an abnormal growth that has invaded surrounding tissues. Dimpling occurs due to fibrotic changes pulling on the skin. Choices A, C, and D are incorrect. A slight asymmetry of the breasts is common and not necessarily indicative of cancer. Bloody discharge from the nipple can be a sign of other conditions like intraductal papilloma. Multiple firm, round, freely movable masses that change with the menstrual cycle are likely benign fibrocystic changes.

Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;

  • A. Confusion or delirium can be a defense against further stress
  • B. Destruction of brain cells has occurred, interrupting mental activity
  • C. Teaching based on information progressing from the simple to the complex
  • D. A minimum of information should be given, since he is unaware of surrounding
Correct Answer: A

Rationale: The correct answer is A. When someone is extremely confused, providing new information slowly and in small amounts can help prevent overwhelming stress and further confusion. This approach allows the individual to process information more effectively and reduces the risk of escalating confusion or delirium as a defense mechanism. Choices B, C, and D are incorrect because destruction of brain cells, teaching progression, and giving minimal information are not directly related to managing confusion in this scenario.

The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketonic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

  • A. Elevated serum acetone level
  • B. Serum alkalosis
  • C. Serum ketone bodies
  • D. Below-normal serum potassium level
Correct Answer: D

Rationale: Step 1: In HHNS, there is severe hyperglycemia leading to osmotic diuresis.
Step 2: Osmotic diuresis causes loss of potassium in urine, leading to hypokalemia.
Step 3: Hypokalemia is a common electrolyte imbalance in HHNS due to excessive urinary loss of potassium.
Step 4: Therefore, the nurse should anticipate a below-normal serum potassium level in a client with HHNS.

Summary:
A: Elevated serum acetone level is seen in diabetic ketoacidosis, not HHNS.
B: Serum alkalosis is not typically associated with HHNS.
C: Serum ketone bodies are elevated in diabetic ketoacidosis, not HHNS.

A patient asks the nurse what side effects to expect from a muscle relaxant medication that has been prescribed. Which of the ff. side effects should the nurse relate?

  • A. Hypoglycaemia
  • B. Drowsiness
  • C. Hypotension
  • D. Dyspnea
Correct Answer: B

Rationale: The correct answer is B: Drowsiness. Muscle relaxants can cause drowsiness as a common side effect due to their sedative properties. This can impair alertness and coordination, so it's crucial for the patient to be aware of this potential effect. Choice A, hypoglycemia, is not typically associated with muscle relaxants. Choice C, hypotension, is more commonly linked to medications like antihypertensives. Choice D, dyspnea, which is difficulty breathing, is not a common side effect of muscle relaxants. Therefore, the nurse should primarily focus on educating the patient about the potential side effect of drowsiness.

Copyright © 2025 Nokea. All rights reserved.