Nursing Process Questions

Correct Answer: D

Rationale: The correct answer is D: Chronic ache or pain. Persistent cough and chronic ache or pain are both common warning signs of cancer. Chronic pain can be a symptom of various types of cancer, signaling the presence of a tumor or cancerous growth. It is important for the client to seek medical evaluation to rule out any underlying serious condition. A: Persistent nausea is not typically considered a common warning sign of cancer. While it can be a symptom in certain types of cancer or due to treatment side effects, it is not as prominent as chronic ache or pain. B: Indigestion is a common symptom that can be caused by various non-cancer-related issues such as dietary habits, stress, or gastrointestinal disorders. It is not typically considered a direct warning sign of cancer. C: Rash is generally not a common warning sign of cancer. Rashes are more commonly associated with skin conditions, allergic reactions, or infections rather than being an indicator of cancer.

Correct Answer: C

Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease. Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites. Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites. Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.

Correct Answer: C

Rationale: Objective data are measurable and observable facts obtained through physical examination or diagnostic tests. In this case, "Respirations 16" is a quantifiable and observable measurement, making it objective data. It is not influenced by personal interpretation or feelings. The other choices, such as "States 'doesn't feel good'", "Reports a headache", and "Nauseated" are subjective data because they are based on the patient's feelings or experiences, which can vary depending on individual perception and interpretation, making them less reliable for making clinical decisions. By focusing on objective data like "Respirations 16", the nurse can provide a more accurate assessment of the patient's condition.

Correct Answer: A

Rationale: The correct answer is A because a nursing diagnosis typically consists of two parts: the problem (Risk for Aspiration) and the related factor (reduced level of consciousness). This format helps clearly identify the client's health issue and its cause. Choice B is incorrect as it refers to a nursing diagnosis focusing on the client's response. Choice C is incorrect as it describes an outcome, not a diagnosis. Choice D is incorrect as a nursing diagnosis should be based on evidence, not made without support. Therefore, the correct choice is A due to the structure and clarity it provides in identifying the client's risk.

Correct Answer: A

Rationale: The correct answer is A: Inspecting for bleeding or cyanosis. During uterosigmoidostomy, the nurse's critical task is to monitor for any signs of bleeding or cyanosis, which are indicators of potential complications such as hemorrhage or impaired blood flow. This involves observing the surgical site for any abnormal bleeding and assessing the skin color for signs of inadequate oxygenation. Inspecting for symptoms of peritonitis (B) is not directly related to this surgical procedure. Assessing the client's allergy to iodine (C) is important but not a critical task during the procedure. Checking for signs of electrolyte losses (D) is important but not as critical as monitoring for immediate postoperative complications like bleeding or cyanosis.