Nursing Process Final Exam Questions

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An oncology nurse educator is speaking to a women’s group about breast cancer. Questions and comments from the audience reveal a misunderstanding of some aspects of the disease. Various members of the audience have made all of the following statements. Which one is accurate?

  • A. Mammography is the most reliable method for detecting breast cancer.
  • B. Breast cancer is the leading killer of women of childbearing age.
  • C. Breast cancer requires a mastectomy.
  • D. Men can develop breast cancer.
Correct Answer: D

Rationale: The correct answer is D: Men can develop breast cancer. This is accurate because although breast cancer is more common in women, men can also develop the disease due to the presence of breast tissue in their bodies. This is a crucial point to emphasize to raise awareness about breast cancer among men.

Incorrect choices:
A: Mammography is not the most reliable method for detecting breast cancer, as it may not detect all types of breast cancer.
B: Breast cancer is not the leading killer of women of childbearing age, as there are other leading causes of death in this age group.
C: Breast cancer does not always require a mastectomy; treatment options vary depending on the individual case.

Summary: Choice D is correct as it highlights the important fact that men can also develop breast cancer, which is often overlooked. Choices A, B, and C are incorrect due to inaccuracies or oversimplifications of the facts related to breast cancer detection, statistics, and treatment.

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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.

A female client recovers from a serious case of insect bites. What skin related advice must the nurse give to the client and all her family members to prevent the recurrence of the ailment?

  • A. Ensure minimum crowd interactions when outdoors
  • B. Apply insect repellent to clothing and exposed skin
  • C. Wear thick woollen clothing to cover the skin while outdoors
  • D. Apply a good sunscreen lotion while going outdoors
Correct Answer: B

Rationale: The correct answer is B: Apply insect repellent to clothing and exposed skin. This advice helps prevent insect bites, reducing the risk of recurrence. Insect repellent creates a barrier against insects, hence minimizing the chances of getting bitten. Other choices are incorrect as they do not directly address the prevention of insect bites. Choice A is vague and does not provide a specific preventive measure. Choice C is incorrect as thick woollen clothing may not necessarily prevent insect bites. Choice D, sunscreen lotion, protects against UV rays, not insect bites.

A client asks the nurse what PSA is. The nurse should reply that is stands for:

  • A. Prostate-specific antigen, which is used to screen for prostate cancer
  • B. Protein serum antigen, which is used to determine protein levels
  • C. Pneumococcal strep antigen, which is bacteria that causes pneumonia
  • D. Papanicolua-specific antigen, which is used to screen for cervical cancer
Correct Answer: A

Rationale: Rationale for Correct Answer (A): Prostate-specific antigen (PSA) is a protein produced by the prostate gland. It is primarily used to screen for prostate cancer by measuring the levels of PSA in the blood. PSA levels can help detect prostate cancer early. Therefore, choice A is the correct answer as it accurately describes PSA and its primary use.

Summary of Incorrect Choices:
B: Protein serum antigen is not a commonly known term in healthcare. There is no specific antigen called "protein serum antigen" used to determine protein levels.
C: Pneumococcal strep antigen is a bacterial antigen that causes pneumonia, not related to PSA used in prostate cancer screening.
D: Papanicolua-specific antigen is not a recognized term. The Papanicolaou test (Pap smear) is used for cervical cancer screening, not a specific antigen like PSA.

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 was brought to the school clinic wuth severe, constant, localized abdominal pain. Abdominal muscles are rigid, and rebound tenderness is present. Peritonitis is suspected. The client is hypotensive and tachycardic. The nursing diagnosis most appropriate to the client’s signs/symptoms is:

  • A. fluid volume deficit related to depletion of intravascular volume
  • B. altered thought process related to toxic effects of elevated ammonia levels
  • C. abdominal pain related to increased intestinal peristalsis
  • D. altered nutrition: less than body requirements related to malabsorption
Correct Answer: A

Rationale: The correct answer is A: fluid volume deficit related to depletion of intravascular volume. Peritonitis causes inflammation of the peritoneum, leading to fluid shifting into the peritoneal cavity, causing hypovolemia. Hypotension and tachycardia are signs of decreased intravascular volume. Rigid abdominal muscles and rebound tenderness indicate peritoneal irritation. Choice B is incorrect because elevated ammonia levels are not associated with the client's symptoms. Choice C is incorrect because increased peristalsis does not explain the client's hypotension and tachycardia. Choice D is incorrect because malabsorption does not align with the client's acute presentation of severe abdominal pain and peritonitis.

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