Fundamentals Nursing Process Questions

Fundamentals Nursing Process Questions Related

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A pregnant client requires immediate but temporary protection from chickenpox. Which type of immunization would be required?

  • A. Naturally acquired active immunization
  • B. Artificially acquired passive
  • C. Artificially acquired active immunization immunization
  • D. Passive immunization
Correct Answer: D

Rationale: The correct answer is D: Passive immunization. This involves administering pre-formed antibodies to provide immediate protection. In the case of a pregnant client needing temporary protection from chickenpox, passive immunization is necessary as it offers immediate immunity without stimulating the client's immune system.

- A (Naturally acquired active immunization): This involves exposure to the pathogen and the body producing its antibodies, which takes time and is not suitable for immediate protection.
- B (Artificially acquired passive immunization): This option doesn't involve providing pre-formed antibodies, which are needed for immediate protection.
- C (Artificially acquired active immunization): This method requires time for the body to develop its immunity, not providing immediate protection as needed in this scenario.

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Which of the ff should qualify as an abnormal result in a Romberg test?

  • A. Hypotension
  • B. Swaying, losing balance, or arm drifting
  • C. Sneezing and wheezing
  • D. Excessive cerumen in the outer ear
Correct Answer: B

Rationale: Step-by-step rationale:
1. In a Romberg test, the patient stands with feet together and eyes closed to assess proprioception.
2. Swaying, losing balance, or arm drifting indicates impaired proprioception, suggesting a positive Romberg sign, which is abnormal.
3. Hypotension (choice A) is not directly related to the Romberg test.
4. Sneezing and wheezing (choice C) are unrelated to the test.
5. Excessive cerumen in the outer ear (choice D) does not affect proprioception.

Summary: Choice B is correct as it directly relates to impaired proprioception, which is abnormal in a Romberg test. Choices A, C, and D are incorrect as they are unrelated to the purpose of the test.

Which food should be avoided by the patient on a low-sodium diet?

  • A. Apples
  • B. Chicken
  • C. Cheese
  • D. Broccoli
Correct Answer: C

Rationale: The correct answer is C: Cheese. Cheese is high in sodium and should be avoided on a low-sodium diet. Sodium can contribute to high blood pressure and other health issues. Apples, chicken, and broccoli are all low in sodium and can be included in a low-sodium diet. Cheese is the only option that is high in sodium, making it the correct choice to avoid.

What is the focus of a diagnostic statement for a collaborative problem?

  • A. The client problem
  • B. The potential complication
  • C. The nursing diagnosis
  • D. The medical diagnosis
Correct Answer: B

Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying potential complications that may arise due to the client's health issue. This is important for developing effective interventions to prevent or manage these complications. Choice A focuses on the client's problem itself, not on potential complications. Choice C is related to nursing diagnosis, not collaborative problems. Choice D refers to medical diagnosis, which is different from collaborative problems involving nursing and other healthcare disciplines. Therefore, B is the correct focus for a diagnostic statement in a collaborative problem scenario.

A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:

  • A. Muscle rigidity and spasms
  • B. Hiccups
  • C. Extrapyramidal reactions
  • D. Respiratory depression
Correct Answer: A

Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect. The anesthesiologist should monitor the client for this adverse reaction. Muscle rigidity and spasms are common with ketamine administration and can affect the client's comfort and safety during the procedure. It is important for the nurse to promptly address any signs of muscle rigidity or spasms to prevent complications.

Summary of why other choices are incorrect:
B: Hiccups - Ketamine can cause hiccups, but it is not the primary side effect to monitor for in this scenario.
C: Extrapyramidal reactions - Ketamine does not typically cause extrapyramidal reactions.
D: Respiratory depression - Ketamine is known for its minimal effect on respiratory depression compared to other anesthetics. Monitoring respiratory depression is still important, but not the primary concern with ketamine administration in this case.

Which of the ff diets does the nurse recommend for clients with hypertension under the physicians guidance?

  • A. The Food Guide Pyramid
  • B. The South Beach Diet
  • C. The Step One Diet
  • D. The Dash diet
Correct Answer: D

Rationale: Step 1: The DASH diet is specifically designed to help lower blood pressure, making it the most appropriate choice for clients with hypertension.
Step 2: The DASH diet emphasizes fruits, vegetables, whole grains, lean proteins, and low-fat dairy, all of which are beneficial for managing hypertension.
Step 3: The diet also limits sodium intake, which is crucial for controlling blood pressure.
Step 4: The other options (A, B, and C) do not have the same evidence-based focus on hypertension management and may not be as effective in lowering blood pressure.

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