Nursing Process Exam Questions

Nursing Process Exam Questions Related

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While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

  • A. Consider cultural differences during this assessment.
  • B. Ask the patient to make eye contact to determine her affect.
  • C. Continue with the interview and document that the patient is depressed.
  • D. Notify the health care provider to recommend a psychological evaluation.
Correct Answer: A

Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness, rather than an indication of depression or dishonesty. By understanding and respecting cultural norms, the nurse can build rapport and trust with the patient. This approach promotes effective communication and a positive patient-provider relationship.

Option B is incorrect because forcing the patient to make eye contact may make her uncomfortable and hinder the therapeutic relationship. Option C is incorrect because assuming the patient is depressed based on cultural differences is inappropriate and may lead to misdiagnosis. Option D is incorrect because jumping to recommendations for a psychological evaluation without considering cultural differences first can be stigmatizing and unnecessary.

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In assessing a post mastectomy client, the nurse determines that the client is in denial. The nurse can best respond by:

  • A. Accepting the denial.
  • B. Supporting the denial.
  • C. Confronting the denial.
  • D. Interpreting the denial.
Correct Answer: C

Rationale: The correct response is C: Confronting the denial. Denial is a defense mechanism that can hinder the client's acceptance and coping with the situation. By confronting the denial in a supportive and empathetic manner, the nurse can help the client acknowledge and process their feelings. Accepting (A) or supporting (B) the denial would enable the client to avoid facing reality. Interpreting (D) the denial may lead to miscommunication or misunderstanding. Confronting the denial encourages the client to address their emotions and move towards acceptance and healing.

When caring for Mr. Reyes, the nurse should assess for

  • A. Decreased carotid pulses
  • B. Altered level of consciousness
  • C. Bleeding from oral cavity
  • D. Absence of deep tendon-reflexes
Correct Answer: B

Rationale: The correct answer is B, Altered level of consciousness, because it is a critical assessment in determining Mr. Reyes's neurological status and overall well-being. Assessing for altered level of consciousness helps identify potential neurological issues, such as brain injury or stroke, which require immediate intervention.

A: Decreased carotid pulses - This is related to cardiovascular assessment, not specific to Mr. Reyes's neurological status.
C: Bleeding from oral cavity - While important to assess for, it is not directly related to Mr. Reyes's neurological status.
D: Absence of deep tendon-reflexes - This is a specific neurological assessment, but altered level of consciousness takes priority in this scenario.

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.

What should the client at risk for developing AIDS be advised to do?

  • A. Abstain from anal intercourse
  • B. Have a semen analysis done
  • C. Have an ELISA test for antibodies
  • D. Inform all sexual contacts
Correct Answer: C

Rationale: The correct answer is C because an ELISA test for antibodies is crucial to detect HIV infection early. This test can help diagnose HIV before symptoms appear, allowing for early intervention and treatment. Choice A is important but not specific to HIV prevention. Choice B is irrelevant for HIV prevention. Choice D, while important, should not take precedence over getting tested for HIV.

When documenting subjective data, the nurse should do which of the following?

  • A. Use the client’s own words placed in quotation marks.
  • B. Paraphrase the information stated by the client.
  • C. Validate the information with the client’s family prior to documentation.
  • D. Record the information using nonspecific words.
Correct Answer: A

Rationale: The correct answer is A because using the client's own words in quotation marks ensures accurate representation of their subjective data. It maintains the integrity of the information provided by the client and improves communication between healthcare providers. Paraphrasing (choice B) may lead to misinterpretation or distortion of the client's statements. Validating with the client's family (choice C) may introduce bias or inaccurate information. Recording with nonspecific words (choice D) decreases the clarity and specificity of the documentation, which is essential for effective communication and decision-making in healthcare.