Nursing Process Questions

Nursing Process Questions Related

Review Nursing Process Questions related questions and content

In a 28-year-old female client who is being successfully treated for Cushing syndrome, the nurse would expect a decline in:

  • A. serum glucose level.
  • B. bone mineralization.
  • C. hair loss
  • D. menstrual flow.
Correct Answer: D

Rationale: The correct answer is D: menstrual flow. In a 28-year-old female with Cushing syndrome, excess cortisol levels can disrupt the menstrual cycle, leading to irregular or absent periods. Successful treatment for Cushing syndrome aims to restore normal cortisol levels, which should result in the resumption of regular menstrual flow. This indicates that the hormonal balance is improving.

Now, let's analyze the other choices:
A: Serum glucose level - While Cushing syndrome can lead to hyperglycemia, successful treatment would aim to normalize glucose levels, not cause a decline.
B: Bone mineralization - Cushing syndrome can cause osteoporosis due to loss of bone density, but successful treatment would help prevent further bone loss rather than decline.
C: Hair loss - Cushing syndrome can cause hair loss, but successful treatment would not necessarily lead to a decline in hair loss as it may take time for hair to regrow.

Therefore, the correct answer is D as it directly relates to the restoration of hormonal

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A client diagnosed with DIC is ordered heparin. What is the reason for this medication?

  • A. Prevent clot formation
  • B. Increase clot formation
  • C. Increased blood flow to target organs
  • D. Decrease blood flow to target organs
Correct Answer: A

Rationale: The correct answer is A: Prevent clot formation. Heparin is an anticoagulant that inhibits the formation of blood clots. In DIC (Disseminated Intravascular Coagulation), there is excessive clotting throughout the body, leading to organ damage. By administering heparin, we aim to prevent further clot formation and reduce the risk of complications.

Choice B is incorrect because heparin does not increase clot formation; it works to inhibit clotting. Choice C is incorrect as heparin does not directly increase blood flow to target organs. Choice D is also incorrect as heparin does not decrease blood flow to target organs; its primary role is anticoagulation.

The nurse is gathering data on a patient. Which data will the nurse report as objective data?

  • A. States “doesn’t feel good”
  • B. Reports a headache
  • C. Respirations 16
  • D. Nauseated
Correct Answer: C

Rationale: Objective data are measurable and observable facts obtained through physical examination or diagnostic tests. In this case, "Respirations 16" is a quantifiable and observable measurement, making it objective data. It is not influenced by personal interpretation or feelings. The other choices, such as "States 'doesn't feel good'", "Reports a headache", and "Nauseated" are subjective data because they are based on the patient's feelings or experiences, which can vary depending on individual perception and interpretation, making them less reliable for making clinical decisions. By focusing on objective data like "Respirations 16", the nurse can provide a more accurate assessment of the patient's condition.

An adult is being taught about a healthy diet. How can the food pyramid help guide the client on his diet?

  • A. By indicating exactly how many servings of each group to eat
  • B. By calculating how many calories the client should have
  • C. By suggesting daily food choices
  • D. By dividing the food into four basic groups
Correct Answer: C

Rationale: The correct answer is C because the food pyramid suggests daily food choices based on the different food groups. It provides a visual guide on the proportions of each food group to consume for a balanced diet. It does not specify the exact number of servings (A), calculate calories (B), or divide food into four basic groups (D). The food pyramid is a tool to help individuals make healthier food choices by emphasizing variety and moderation.

What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?

  • A. Fr. 5
  • B. Fr. 12
  • C. Fr. 10
  • D. Fr. 18
Correct Answer: A

Rationale: The correct size of suction catheter for James would be Fr. 5. The selection of suction catheter size is based on the patient's height and weight, as well as the secretions to be cleared. A Fr. 5 catheter is appropriate for an average adult like James, as it balances between being too small or too large. Fr. 12 and Fr. 18 are too large for his size and could cause trauma, while Fr. 10 is slightly larger than needed, increasing the risk of mucosal damage. Therefore, Fr. 5 is the most suitable choice for James.

A seizure characterized by loss of consciousness and tonic spasms of the trunk and extremities rapidly followed by repetitive generalized clonic jerking is classified as:

  • A. Focal seizure
  • B. Jacksonian seizure
  • C. Generalized seizure
  • D. Partial seizure
Correct Answer: C

Rationale: The correct answer is C: Generalized seizure. This type of seizure involves both hemispheres of the brain from the onset, leading to loss of consciousness and tonic-clonic jerking. It is characterized by widespread, synchronized electrical discharges.

A: Focal seizures start in one area of the brain, leading to localized symptoms without loss of consciousness.
B: Jacksonian seizures are a type of focal seizure characterized by a progression of jerking movements from one body part to another.
D: Partial seizures involve only one part of the brain, leading to localized symptoms or altered consciousness without loss of awareness.

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