Fundamentals Nursing Process Questions

Fundamentals Nursing Process Questions Related

Review Fundamentals Nursing Process Questions related questions and content

What is the primary purpose of the outcome identification and planning step of the nursing process?

  • A. To collect and analyze data to establish a database
  • B. To interpret and analyze data so as to identify health problems
  • C. To write appropriate client-centered nursing diagnoses
  • D. To design a plan of care for and with the client
Correct Answer: D

Rationale: The primary purpose of the outcome identification and planning step of the nursing process (step 3) is to design a plan of care for and with the client. This involves setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to address the client's health problems. By involving the client in the planning process, it promotes client autonomy and ensures that the plan is tailored to their individual needs and preferences. Options A and B focus on data collection and analysis, which are steps 1 and 2 of the nursing process. Option C refers to nursing diagnosis, which is part of step 2 (diagnosis). Therefore, option D is the correct answer as it pertains to the specific purpose of the outcome identification and planning step.

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When the LPN is assisting the patient to use an incentive spirometer, which of the following actions by the patient indicates that the patient needs further teaching on how to use the spirometer?

  • A. Taking two normal breaths before use.
  • B. Sitting upright before use.
  • C. Inhaling deeply to reach target.
  • D. Exhaling deeply to reach target.
Correct Answer: D

Rationale: The correct answer is D because exhaling deeply before using the spirometer is incorrect. The purpose of the incentive spirometer is to encourage deep inhalation to improve lung function. Exhaling deeply before using the spirometer goes against this goal and may hinder the effectiveness of the device. Choices A, B, and C are all correct actions when using the spirometer. Taking two normal breaths helps to prepare the lungs, sitting upright optimizes lung expansion, and inhaling deeply to reach the target helps to improve lung ventilation.

You would not find which of the following assessments in a patient with severe anemia?

  • A. Pallor
  • B. Fatigue
  • C. Cold sensitivity
  • D. Dyspnea only on exertion
Correct Answer: C

Rationale: The correct answer is C: Cold sensitivity. Severe anemia leads to decreased oxygen delivery to tissues, causing symptoms like pallor, fatigue, and dyspnea on exertion due to the body compensating for low oxygen levels. Cold sensitivity is not a common symptom associated with anemia. The other choices are directly related to severe anemia due to the lack of oxygen delivery to tissues.

Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?

  • A. Fruity odor of the breath
  • B. shallow, deep respirations
  • C. severe dehydration
  • D. profuse sweating
Correct Answer: C

Rationale: The correct answer is C: severe dehydration. In HHNK coma, the body tries to eliminate excess glucose through frequent urination, leading to dehydration. This results in decreased blood volume, causing hypotension and tachycardia. Signs include dry mucous membranes, poor skin turgor, and concentrated urine output. Fruity odor of the breath (A) is associated with diabetic ketoacidosis, not HHNK coma. Shallow, deep respirations (B) and profuse sweating (D) are not typically associated with HHNK coma.

Which of the following parts of neuron transmits impulses away from the cell body?

  • A. Dendrite
  • B. . Neurolemma
  • C. Axon
  • D. Synapse
Correct Answer: C

Rationale: The correct answer is C: Axon. The axon is the part of the neuron that transmits impulses away from the cell body towards other neurons, muscles, or glands. Its structure allows for the rapid transmission of electrical signals.

Rationale:
1. Dendrites receive signals and transmit them towards the cell body, so A is incorrect.
2. Neurolemma is the outermost layer of a Schwann cell, not a part of the neuron responsible for transmitting impulses, so B is incorrect.
3. The synapse is the junction between two neurons where communication occurs, not a part of the neuron transmitting impulses, so D is incorrect.

Which of the following is an early sign of anemia?

  • A. Palpitations
  • B. Pallor
  • C. Glossitis
  • D. Weight loss
Correct Answer: B

Rationale: The correct answer is B: Pallor. Pallor, which refers to paleness of the skin, is an early sign of anemia due to decreased red blood cell levels. Anemia causes reduced oxygen delivery to tissues, leading to paleness. Palpitations (A) may occur in anemia but are not an early sign. Glossitis (C) and weight loss (D) are not typically early signs of anemia and are more commonly associated with other health conditions.

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