Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity. Myocardial infarction, hypertension, and progressive systemic sclerosis can lead to impaired circulation and skin breakdown. Clients with these conditions are at risk for pressure ulcers due to decreased blood flow and compromised skin integrity. The other options, B: Imbalanced nutrition, C: Constipation, and D: Ineffective thermoregulation, do not directly relate to the client's conditions or the potential complications associated with them. Therefore, the most appropriate nursing diagnosis for this client would be A: Risk for impaired skin integrity.

Correct Answer: B

Rationale: The correct answer is B: An above-normal anti-deoxyribonucleic acid. In SLE, the body produces antibodies against its own DNA, leading to the presence of anti-dsDNA antibodies. Elevated levels of anti-dsDNA antibodies are specific to SLE, confirming the diagnosis. A: Increased total serum complement levels are seen in SLE due to complement activation but are not specific to SLE. C: Negative antinuclear antibody test is not consistent with SLE, as ANA positivity is common in SLE. D: Negative lupus erythematosus cell test is not specific to SLE as lupus erythematosus cells are not always present.

Correct Answer: B

Rationale: Correct Answer: B (State Nurse Practice Acts) Rationale: State Nurse Practice Acts outline the legal scope of nursing practice, including standards for setting priorities, identifying client outcomes, and selecting evidence-based nursing interventions. These laws are specific to nursing practice, ensuring that nurses follow guidelines tailored to their profession. Nurses must adhere to these standards to provide safe and effective care. Summary of Incorrect Choices: A: Professional physicians' organizations - While physicians' organizations may provide guidelines for medical practice, they do not set standards specific to nursing practice. C: The Joint Commission - The Joint Commission focuses on accreditation for healthcare organizations, not setting standards for nursing practice. D: The Agency for Health Care Research and Quality - AHRQ conducts research and provides evidence-based information but does not establish standards for nursing practice.

Correct Answer: A

Rationale: Correct Answer: A: Respiratory acidosis Rationale: 1. Respiratory acidosis is caused by inadequate ventilation leading to increased PCO? and decreased pH. 2. Low pH indicates acidosis, and high PCO? indicates respiratory component. 3. Metabolic acidosis (B) results from non-respiratory causes. 4. Respiratory alkalosis (C) is characterized by high pH and low PCO?. 5. Metabolic alkalosis (D) is caused by non-respiratory factors with high pH.

Correct Answer: B

Rationale: The correct answer is B because right-sided weakness is typically associated with damage or impairment in the left lobe of the brain. The brain controls the opposite side of the body, so weakness on the right side indicates left brain involvement. This is known as contralateral control. The other choices are incorrect because expressive aphasia is associated with left brain damage, problems in judging distance and proprioception are related to parietal lobe damage, and orientation to time and space is more related to frontal lobe damage. Therefore, the most accurate analysis by the nurse would be to consider the affected lobe as the right lobe in this case.