Nursing Process Questions

Nursing Process Questions Related

Review Nursing Process Questions related questions and content

. Which of the following laboratory test results would suggest to the nurse that a client has a corticotrophin- secreting pituitary adenoma?

  • A. High corticotropin and low cortisol levels
  • B. high corticotropin and high cortisol levels
  • C. Low corticotropin and high cortisol levels
  • D. Low corticotropin and low cortisol levels
Correct Answer: B

Rationale: Step-by-step rationale:
1. Corticotropin-secreting pituitary adenoma leads to excess adrenocorticotropic hormone (ACTH) production.
2. High corticotropin levels would be expected due to the adenoma's overproduction.
3. The high cortisol levels occur as a result of increased ACTH stimulating cortisol release from the adrenal glands.
4. Therefore, choice B (high corticotropin and high cortisol levels) is the correct answer.

Summary:
- Choice A is incorrect because low cortisol levels would not be expected in a client with a corticotrophin-secreting pituitary adenoma.
- Choice C is incorrect because low corticotropin levels would not align with the excessive ACTH production from the adenoma.
- Choice D is incorrect as both low corticotropin and low cortisol levels would not be consistent with the pathophysiology of a corticotrophin-secreting pituitary adenoma.

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A client has undergone the Snellen eye chart test and has 20/40 vision. Which of the ff is true for this client?

  • A. The client sees letters at 20 feet that others can read at 40 feet
  • B. The client sees letters at 40 feet that others can read at 20 feet
  • C. The client sees colors at 20 feet that others can see at 40 feet
  • D. The client sees colors at 40 feet that others can see at 20 feet
Correct Answer: A

Rationale: The correct answer is A. In the Snellen eye chart test, the first number (20) represents the distance at which the client is viewing the chart, and the second number (40) represents the distance at which a person with normal vision can read the same line. Therefore, a client with 20/40 vision sees letters at 20 feet that others with normal vision can read at 40 feet.

Choices B, C, and D are incorrect because they do not accurately reflect the interpretation of the 20/40 vision result from the Snellen eye chart test. B is incorrect because the client does not see letters at 40 feet that others can read at 20 feet. Choices C and D are incorrect because the Snellen eye chart test measures visual acuity, not color perception.

To monitor the severity of a patient’s heart failure, which of the ff. assessments is the most appropriate for the nurse to include as a daily assessment in the plan of care?

  • A. Weight
  • B. Appetite
  • C. Calorie count
  • D. Abdominal girth
Correct Answer: A

Rationale: The correct answer is A: Weight. Monitoring daily weight is crucial in assessing fluid retention and worsening heart failure symptoms. Weight gain can indicate fluid overload, a common complication in heart failure. The other choices (B: Appetite, C: Calorie count, and D: Abdominal girth) are not as directly related to monitoring heart failure severity. Appetite and calorie count may be affected by various factors unrelated to heart failure, while abdominal girth may not provide specific information on fluid status. Monitoring weight allows for early intervention and adjustments in treatment to prevent exacerbation of heart failure symptoms.

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: The correct answer is C because respirations of 16 is an observable and measurable data point that can be quantified. Objective data are factual, measurable, and based on observable phenomena. In contrast, choices A, B, and D are subjective data as they rely on the patient's feelings or experiences, which are not directly measurable or observable by the nurse. Reporting a headache or feeling nauseated are subjective symptoms that are based on the patient's perception and cannot be verified without further assessment. Therefore, only choice C provides objective data that can be accurately reported by the nurse.

Following the American Cancer Society guidelines, the nurse should recommend that the women:

  • A. Perform breast self-examination annually
  • B. Have a physician conduct a clinical
  • C. Have a mammogram annually examination every 2 years
  • D. Have a normal receptor assay annually
Correct Answer: C

Rationale: The correct answer is C because the American Cancer Society recommends women to have a mammogram annually starting at age 45, then have the option to transition to biennial screening at age 55. This recommendation is based on evidence that regular mammograms can help detect breast cancer early, increasing chances of successful treatment. Choice A is incorrect because self-examinations are no longer recommended as a routine screening method. Choice B is incorrect as clinical breast exams are not as effective as mammograms for detecting breast cancer. Choice D is incorrect as normal receptor assays are not part of routine breast cancer screening guidelines.

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, such as vital signs. Respirations of 16 are a specific numerical measurement that can be quantified. This makes choice C the correct answer as it is factual and quantifiable. Choices A, B, and D are subjective data, as they rely on the patient's feelings or experiences, which are open to interpretation and not measurable. Therefore, the nurse should report choice C as objective data as it provides concrete information for assessment and decision-making.

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