Nursing Process Exam Questions

Correct Answer: D

Rationale: The correct answer is D because a respiratory rate of 8 breaths/min indicates respiratory depression, a serious adverse effect of morphine. Morphine is a central nervous system depressant that can suppress the respiratory drive, leading to hypoventilation and potentially respiratory failure. This is a life-threatening complication that requires immediate intervention. A: Voiding of 350mL of concentrated urine is not typically associated with morphine use. B: An irregular heart rate of 82 beats/min is within a normal range and not a common adverse effect of morphine. C: Pupils constricted and equal is a common side effect of morphine due to its action on the central nervous system, not necessarily indicating an adverse effect.

Correct Answer: B

Rationale: The correct answer is B: Focused. When a nurse inspects a postoperative incision site for infection, they are conducting a focused assessment. This type of assessment is specific to a particular issue or body system, in this case, the incision site. By focusing solely on the incision site, the nurse can thoroughly evaluate for signs of infection, such as redness, swelling, warmth, or discharge. A: Complete assessments involve a comprehensive evaluation of all body systems and are not necessary for this specific situation. C: General assessments are broad and not targeted towards a specific issue like infection at an incision site. D: Time-lapse assessments involve comparing current findings to previous assessments over a period of time, which is not relevant to immediately identifying signs of infection. In summary, the correct answer is focused because it allows for a detailed evaluation of the incision site specifically for signs of infection, unlike the other options that are either too broad or not relevant to the situation.

Correct Answer: C

Rationale: The correct answer is C: �Are you feeling frightened? I�m here and I will help you.� This response acknowledges the resident�s feelings, offers reassurance, and provides support, focusing on the resident's emotional needs rather than the accuracy of her statements. It shows empathy and validation of her feelings, which can help calm the resident and build trust. Choice A is incorrect because it dismisses the resident's feelings and reality, which can lead to increased distress and confusion. Choice B is incorrect as it doesn't address the resident's emotional state or offer immediate support. Choice D is incorrect as it focuses on correcting the resident's perception rather than providing emotional support, which may lead to further distress.

Correct Answer: A

Rationale: The correct answer is A: Sinusitis. Allergic rhinitis causes inflammation in the nasal passages, leading to congestion and blockage of the sinuses. If the patient does not comply with the treatment regimen, the inflammation can worsen, increasing the risk of developing sinusitis, which is an infection or inflammation of the sinuses. Sinusitis can result in severe pain, pressure, and potentially lead to complications. Summary of other choices: B: Lymphadenopathy - Enlargement of lymph nodes, not directly related to non-compliance with treatment for allergic rhinitis. C: Anaphylaxis - Life-threatening allergic reaction, not a typical consequence of non-compliance with treatment for allergic rhinitis. D: Angioedema - Swelling of deeper layers of skin, usually associated with allergies but not a common outcome of non-compliance with treatment for allergic rhinitis.

Correct Answer: C

Rationale: The correct answer is C: Myotic. Myotic eyedrops constrict the pupil, allowing aqueous humor to flow around the lens. Myotic agents, such as pilocarpine, work by stimulating the sphincter muscle of the iris. Osmotic eyedrops (A) reduce intraocular pressure, mydriatic eyedrops (B) dilate the pupil, and cycloplegic eyedrops (D) paralyze the ciliary muscle to prevent accommodation.