Nursing Process Questions

Correct Answer: D

Rationale: The correct answer is D: anorexia. In the early stage of hepatic inflammatory disorder, anorexia is the most likely symptom/sign. This is because hepatic inflammation can lead to a decrease in appetite, resulting in anorexia. Dark urine (A) is commonly associated with liver dysfunction but typically occurs later in the disease process. Occult blood in stools (B) is more indicative of gastrointestinal bleeding rather than early hepatic inflammation. Ascites (C) is the accumulation of fluid in the abdominal cavity and is a later manifestation of liver disease. Therefore, anorexia is the most likely symptom in the early stages of hepatic inflammatory disorder.

Correct Answer: A

Rationale: The correct answer is A because successful treatment of diabetes insipidus aims to reduce excessive urine output and dehydration. A fluid intake of less than 2,500mL in 24 hours indicates proper control of fluid balance. Choice B is incorrect because urine output of more than 200mL/hour suggests ongoing excessive fluid loss, which is not indicative of successful treatment. Choice C is incorrect as a blood pressure of 90/50mmHg is low and may indicate hypotension, which is not a specific indicator of successful diabetes insipidus treatment. Choice D is incorrect because a pulse rate of 126 beats/min is not a direct marker of diabetes insipidus treatment success. In summary, the correct indicator of successful treatment of diabetes insipidus is a reduction in fluid intake, option A, as it signifies improved fluid balance and hydration status.

Correct Answer: D

Rationale: The correct answer is D: Conjunctivae. Pallor is best assessed in the conjunctivae due to the transparent nature of the tissue, allowing for easy observation of paleness. The conjunctivae are the mucous membranes lining the inner surface of the eyelids and covering the sclera. Anemia can cause decreased hemoglobin levels, resulting in paleness of the mucous membranes. Assessing the scalp (A), chest (B), or axillae (C) may not provide a clear indication of pallor related to anemia. The conjunctivae offer a direct and reliable site to assess for pallor in patients with anemia.

Correct Answer: A

Rationale: The correct answer is A: once a month after menstruation. Performing BSE at this time helps ensure consistent examination when breasts are less tender or swollen, making it easier to detect abnormalities. Performing it once a month ensures regular monitoring for any changes. Choices B, C, and D are incorrect because they do not provide the recommended frequency or timing for an effective BSE. BSE should be done monthly after menstruation to increase the chances of early detection of breast cancer.

Correct Answer: B

Rationale: The correct answer is B: Help the client don thromboembolic stocking or support hose during waking hours. This intervention helps decrease the risk for thrombus formation in polycythemia vera by promoting venous return and preventing blood pooling in the lower extremities. Compression stockings improve circulation and reduce the risk of blood clots. Isometric exercises (choice A) may increase blood pressure and heart rate, potentially worsening the risk of thrombus formation. Drinking excess fluid (choice C) can lead to hypervolemia and increase the risk of clotting. Resting immediately if chest pain develops (choice D) is important but does not directly address the prevention of thrombus formation in polycythemia vera.