Nursing Process 1 Test Questions

Correct Answer: A

Rationale: The correct answer is A: Removal of the transplanted kidney. Hyperacute rejection is a severe and immediate immune response to the transplanted organ. In this case, the transplanted kidney must be removed promptly to prevent further complications, as it is irreversibly damaged. High-dose IV cyclosporine (B) is used for immunosuppression but is not effective in treating hyperacute rejection. Bone marrow transplant (C) is not indicated for kidney rejection. Intra-abdominal instillation of methylprednisolone sodium succinate (D) is used for acute rejection, not hyperacute rejection.

Correct Answer: D

Rationale: The correct answer is D, assess vital signs, as it is crucial to monitor the client's hemodynamic stability and response to treatment during the critical initial 24 hours of Addisonian crisis. Vital signs such as blood pressure, heart rate, and respiratory rate provide valuable information about the client's condition and response to therapy. Weighing the client (choice A) and testing urine for ketones (choice C) may be important but not as immediately critical as monitoring vital signs. Administering oral hydrocortisone (choice B) is essential for treatment but does not require frequent administration within the first 24 hours.

Correct Answer: D

Rationale: Step-by-step rationale: 1. A balanced and varied diet provides essential nutrients for immune function. 2. Including a wide range of foods ensures intake of vitamins, minerals, and antioxidants crucial for immune health. 3. Avoiding extremes like excessive immune-enhancing formulas or eliminating polyunsaturated fatty acids maintains balance. 4. Essential fatty acids and omega-3 fatty acids are beneficial but should be part of a well-rounded diet. 5. For clients with immune-mediated disorders, individualized dietary advice may be necessary. Summary: - A: Immune-enhancing formulas may not be necessary and could disrupt balance. - B: Avoiding all polyunsaturated fatty acids is not advisable as some are essential for health. - C: Increasing essential fatty acids is beneficial but should be part of a balanced diet.

Correct Answer: C

Rationale: The correct answer is C: Hypoglycemia. At 4:30 p.m., after taking the morning insulin, the client's blood sugar may have dropped too low, leading to symptoms like headache, sweating, tremor, pallor, and nervousness. Regular insulin and NPH insulin peak at different times, causing a potential mismatch in insulin action, leading to hypoglycemia. Hyperglycemia (A) would present with different symptoms like increased thirst and urination. Hyperuricemia (B) is an excess of uric acid in the blood and does not typically present with these symptoms. Hypochondria (D) is a psychological condition and not related to the client's physical symptoms.

Correct Answer: C

Rationale: The correct answer is C: Perform a thorough nursing health history. This method is the best for gathering information about a patient's habits and lifestyle patterns because it involves asking specific questions related to the patient's daily routines, habits, and lifestyle choices. By obtaining a comprehensive health history, the nurse can gather valuable information about the patient's diet, exercise habits, sleep patterns, stress levels, substance use, and other lifestyle factors that may impact their health. Reviewing lab results (A) may provide some information but not specifically about habits and lifestyle. Conducting a physical assessment (B) focuses more on the patient's physical condition rather than lifestyle. Prolonging the termination phase of the interview (D) is not a method of data collection and does not focus on gathering information about habits and lifestyle patterns.