Fundamentals of Nursing Nursing Process Questions

Fundamentals of Nursing Nursing Process Questions Related

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Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:

  • A. For its synergestic effect
  • B. Because of the client's resistance to
  • C. To rule out cholinergic crisis Neostigmine
  • D. To confirm the diagnosis of myasthenia
Correct Answer: C

Rationale: The correct answer is C: To rule out cholinergic crisis Neostigmine. Edrophonium HCL is a short-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis, as both conditions present similarly with muscle weakness. Administering edrophonium HCL will help determine if the patient's worsening weakness is due to excessive cholinergic stimulation from neostigmine (cholinergic crisis) or inadequate acetylcholine at the neuromuscular junction (myasthenic crisis). This step is crucial for proper management, as treating cholinergic crisis with more cholinesterase inhibitors like neostigmine can worsen symptoms.

Incorrect choices:
A: For its synergistic effect - Edrophonium HCL does not have a synergistic effect with neostigmine.
B: Because of the client's resistance to - Resistance to neostigmine is not a reason to administer edrophonium H

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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. This involves analyzing assessment data, utilizing critical thinking skills to identify patient problems, and formulating nursing diagnoses. Diagnostic reasoning is the process of synthesizing information to make clinical judgments and determine appropriate interventions.

A: Assigning clinical cues - Incorrect. This refers to identifying observable signs or symptoms, not the process of developing a nursing diagnosis.
B: Defining characteristics - Incorrect. This term is often used to describe the symptoms or manifestations associated with a nursing diagnosis, not the process of deriving the diagnosis.
D: Diagnostic labeling - Incorrect. This is the final step in the nursing diagnosis process where the nurse assigns a label to the identified patient problem, not the process of critical thinking and data analysis.

Which type of neuron transmits impulses from the central nervous system to the muscles and glands?

  • A. Afferent
  • B. Efferent
  • C. Affective
  • D. Effective
Correct Answer: B

Rationale: The correct answer is B: Efferent. Efferent neurons transmit signals from the central nervous system to muscles and glands, controlling movement and secretion. Afferent neurons carry signals from sensory receptors to the central nervous system, not towards muscles or glands. "Affective" relates to emotions, not neural function. "Effective" does not describe the direction of signal transmission in the nervous system. Therefore, B is the correct choice.

Which of the following responses indicates sympathetic nervous system function?

  • A. Tachycardia, dilated pupils
  • B. Hypoglycaemia, headache
  • C. Increased peristalsis, abdominal cramping
  • D. Pupil constriction, bronchoconstriction
Correct Answer: A

Rationale: The correct answer is A because tachycardia (increased heart rate) and dilated pupils are classic responses of the sympathetic nervous system activation. Sympathetic nervous system is responsible for the fight or flight response, leading to increased heart rate and dilated pupils to prepare the body for quick action.

Choice B is incorrect because hypoglycemia and headache are not specific to sympathetic nervous system function. Choice C is incorrect because increased peristalsis and abdominal cramping are more indicative of parasympathetic nervous system activity. Choice D is incorrect because pupil constriction and bronchoconstriction are actions of the parasympathetic nervous system, responsible for rest and digest functions.

Which method of data collection will the nurse use to establish a patient’s database?

  • A. Reviewing the current literature to determine evidence-based nursing actions
  • B. Checking orders for diagnostic and laboratory tests
  • C. Performing a physical examination
  • D. Ordering medications
Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather comprehensive data about the patient's health status, including vital signs, physical appearance, and potential health issues. It provides valuable information for developing an individualized care plan. Reviewing literature (A) is important but not for establishing a patient's database. Checking orders (B) and ordering medications (D) are part of the treatment process and do not directly contribute to establishing the initial patient database.

A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:

  • A. Hypertension
  • B. Tachycardia
  • C. Oliguria
  • D. Tachypnea
Correct Answer: A

Rationale: The correct answer is A: Hypertension. In hypovolemia, the body compensates by increasing heart rate (B: Tachycardia) to maintain perfusion, decreasing urine output (C: Oliguria) to conserve fluid, and increasing respiratory rate (D: Tachypnea) to improve oxygenation. Hypertension is not a typical compensatory response to hypovolemia; instead, blood pressure tends to decrease due to reduced circulating volume. Therefore, hypertension is the symptom that would not be expected in a patient with hypovolemic shock.

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