Fundamentals of Nursing Nursing Process Questions

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During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?

  • A. Recommending that the client discontinue chemotherapy
  • B. Providing a solution of hydrogen peroxide and water for use as a mouth rinse
  • C. monitoring the client’s platelet and leukocyte counts
  • D. Checking regularly for signs and symptoms of stomatitis
Correct Answer: B

Rationale: Step 1: Providing a solution of hydrogen peroxide and water as a mouth rinse helps in reducing the pain of stomatitis by promoting oral hygiene and preventing infections.
Step 2: Hydrogen peroxide has antimicrobial properties that can help in reducing bacteria in the mouth, which can worsen stomatitis.
Step 3: Rinsing with this solution can also help in cleansing the oral mucosa and reducing inflammation, thereby decreasing pain.
Step 4: This intervention directly addresses the nursing diagnosis of impaired oral mucous membrane and is focused on symptom management.
Summary:
A: Recommending the client to discontinue chemotherapy is not a feasible option as it is essential for treating cancer.
C: Monitoring platelet and leukocyte counts is important but does not directly address the pain of stomatitis.
D: Checking for signs and symptoms is necessary but does not provide direct relief for the pain of stomatitis.

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The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client’s health status. Which of the following would the nurse identify as a subjective cue?

  • A. Sharp pain in the knee
  • B. Small bloody drainage on dressing
  • C. Temperature of 102 degrees F
  • D. Pulse rate of 90 beats per minute
Correct Answer: A

Rationale: The correct answer is A because sharp pain is a subjective cue as it is based on the client's personal experience and perception. The client is the only one who can report the presence and intensity of pain.

B: Small bloody drainage is an objective cue that can be observed and measured by the nurse.

C: Temperature of 102 degrees F is an objective cue that can be measured using a thermometer.

D: Pulse rate of 90 beats per minute is an objective cue that can be measured using a pulse oximeter.

In summary, subjective cues are based on the client's feelings and perceptions, while objective cues are observable and measurable by the healthcare provider.

Which statement, from a participant attending the class on AIDS prevention, indicates an understanding on how to reduce transmission of HIV?

  • A. Mother’s who are HIV positive should still be encouraged to breastfeed their babies because beast milk is superior to cow’s milk
  • B. I think a needle exchange program, where clean needles are exchanged for dirty needles, should be offered in every city
  • C. Females taking birth control pills are protected from getting HIV
  • D. It’s okay to use natural skin condoms since they offer the same protection as the latex condoms
Correct Answer: B

Rationale: The correct answer is B. This statement shows an understanding of reducing HIV transmission by promoting harm reduction strategies like needle exchange programs, which help prevent sharing of contaminated needles. This approach is evidence-based and effective in reducing the spread of HIV among injection drug users.

Choice A is incorrect because breastfeeding by HIV-positive mothers can transmit the virus to infants. Choice C is incorrect as birth control pills do not protect against HIV, only against pregnancy. Choice D is incorrect as natural skin condoms do not provide the same level of protection against HIV as latex condoms do.

When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen?

  • A. Bread
  • B. Oranges
  • C. Carrots
  • D. Strawberries
Correct Answer: D

Rationale: The correct answer is D: Strawberries. Strawberries are a common allergen due to their high allergenic potential. When taking a dietary history, it is important to identify potential allergens to prevent adverse reactions. Oranges, carrots, and bread are not as commonly associated with allergies compared to strawberries. Identifying common allergens helps in providing safe and appropriate dietary recommendations for clients.

The nurse is developing a teaching plan for a patient. Which of the following is a modifiable risk factor for the development of hypertension? i.Race iv.Sedentary lifestyle ii.High cholesterol v.Age iii.Cigarette smoking

  • A. 1 and 2
  • B. 2, 3, 4 and 5
  • C. 2, 3 and 4
  • D. All of the above
Correct Answer: C

Rationale: The correct answer is C: 2, 3, and 4. High cholesterol, cigarette smoking, and a sedentary lifestyle are modifiable risk factors for developing hypertension. High cholesterol can lead to atherosclerosis, increasing blood pressure. Smoking can constrict blood vessels, raising blood pressure. Sedentary lifestyle can lead to obesity and overall poor cardiovascular health, contributing to hypertension. Race and age are non-modifiable risk factors. Choice A is incorrect because it includes race, a non-modifiable factor. Choice B is incorrect because it includes age, which is also non-modifiable. Choice D is incorrect because it includes all factors, including non-modifiable ones.

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?

  • A. Assigning clinical cues
  • B. Defining characteristics
  • C. Diagnostic reasoning NursingStoreRN
  • D. Diagnostic labeling
Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. The nurse is using assessment data to analyze, interpret, and make a judgement about the patient's condition. This process involves critical thinking skills to develop a nursing diagnosis. Choice A (Assigning clinical cues) is incorrect because it refers to identifying specific signs and symptoms. Choice B (Defining characteristics) is incorrect as it pertains to the features of a diagnosed condition. Choice D (Diagnostic labeling) is incorrect because it focuses on naming a specific nursing diagnosis. Diagnostic reasoning encompasses the entire process of analyzing data, making connections, and formulating a nursing diagnosis based on critical thinking.

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