Nursing Process Exam Questions

Nursing Process Exam Questions Related

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The nurse practitioner assesses a client in the physician’s office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?

  • A. Facial erythema, profuse proteinuria, pleuritis, fever, and weight loss
  • B. Pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers
  • C. Weight gain, hypervigilance, hypothermia, and edema of the legs
  • D. Hypothermia, weight gain, lethargy, and edema of the arms
Correct Answer: B

Rationale: The correct answer is B because the assessment findings of pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers are classic manifestations of systemic lupus erythematosus (SLE). Pericarditis can present as chest pain aggravated by deep breathing or lying flat, photosensitivity refers to skin rashes triggered by sunlight exposure, polyarthralgia involves joint pain in multiple joints, and painful mucous membrane ulcers are common in the mouth or nose. These findings align with the diagnostic criteria for SLE.

Choices A, C, and D are incorrect because they do not align with the typical presentation of SLE. Choice A includes facial erythema which is a common symptom, but the presence of profuse proteinuria, pleuritis, fever, and weight loss are not specific to SLE. Choices C and D include symptoms like weight gain, hypothermia, and edema which are not characteristic of SLE.

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A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?

  • A. Risk for impaired skin integrity
  • B. Risk for infection
  • C. Spiritual distress
  • D. Reflex urinary incontinence
Correct Answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity. This is the highest priority as patients with spinal cord injuries are at high risk for pressure ulcers due to immobility. Preventing skin breakdown is crucial to avoid complications. Choices B, C, and D are not as urgent. Choice B may be a concern but preventing skin breakdown takes precedence. Choices C and D are important but not life-threatening like potential skin issues in this patient population.

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

  • A. Infusing IV fluids rapidly as ordered
  • B. Administering glucose-containing IV
  • C. Encouraging increased oral intake fluids as ordered
  • D. Restricting fluids
Correct Answer: D

Rationale: The correct answer is D: Restricting fluids. In SIADH, there is an excess of antidiuretic hormone leading to water retention and dilutional hyponatremia. Restricting fluids helps to prevent further water retention and hyponatremia. Rapid IV fluid infusion (A) worsens the condition by further diluting sodium levels. Administering glucose-containing IV (B) is not directly related to treating SIADH. Encouraging increased oral intake (C) can exacerbate the condition by increasing fluid intake.

Mr. Galino is diagnosed to have Raynaud’s disease. Nurse Oliver gives instructions to the client to stop smoking because it causes:

  • A. cyanosis and necrosis
  • B. vasoconstriction, vasospasms
  • C. decreased blood oxygen content
  • D. pain and tingling
Correct Answer: B

Rationale: The correct answer is B: vasoconstriction, vasospasms.
1. Raynaud's disease involves exaggerated vasoconstriction and vasospasms of blood vessels in response to cold or stress.
2. Smoking aggravates vasoconstriction and vasospasms by constricting blood vessels further.
3. This can worsen symptoms for individuals with Raynaud's disease.
4. Choices A, C, and D do not directly relate to the mechanism of Raynaud's disease and smoking.

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?

  • A. Risk nursing diagnosis
  • B. Actual nursing diagnosis
  • C. Possible nursing diagnosis
  • D. Wellness diagnosis
Correct Answer: B

Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, such as signs and symptoms exhibited by the patient. This helps in identifying the specific health issues that the patient is currently experiencing. In contrast, a risk nursing diagnosis is focused on potential health problems that the patient may develop in the future. Possible nursing diagnosis involves uncertain or unclear health issues that require further assessment. Wellness diagnosis is aimed at enhancing health and promoting well-being, rather than addressing existing health problems. Therefore, the presence of major defining characteristics is crucial in confirming an actual nursing diagnosis.

In order to educate clients, the nurse should understand that the most common site of cancer for a female is the:

  • A. Uterine cervix
  • B. Vagina
  • C. Uterine body
  • D. Fallopian tube
Correct Answer: C

Rationale: The correct answer is C: Uterine body. The rationale is that the most common site of cancer for females is uterine body, specifically endometrial cancer. This is due to the high prevalence of hormonal imbalances and estrogen exposure, which are risk factors for this type of cancer. The other choices, A: Uterine cervix, B: Vagina, and D: Fallopian tube, are less common sites of cancer in females compared to the uterine body. Understanding the prevalence and risk factors associated with each site of cancer is crucial for nurses to educate clients effectively.

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