Nursing Process Practice Questions

Correct Answer: C

Rationale: The correct answer is C: Autonomy. Autonomy is the ethical principle that upholds an individual's right to make decisions about their own healthcare. In this scenario, the client is expressing her desire to not undergo surgery, which is her right as an autonomous individual. The nurse must respect her decision even if it goes against medical advice. Beneficence (A) is the ethical principle of doing good for the patient, but in this case, respecting the client's autonomy takes precedence. Advocacy (B) involves supporting the client's best interests, which could align with autonomy in this case. Justice (D) refers to fairness and equal treatment, but it is not directly applicable to the client's decision regarding surgery.

Correct Answer: D

Rationale: The correct answer is D: Pallor, tachycardia, and a sore tongue. Pernicious anemia is caused by a deficiency in vitamin B12, leading to symptoms such as pallor (due to decreased red blood cells), tachycardia (as the heart works harder to compensate for decreased oxygen-carrying capacity of the blood), and a sore tongue (due to inflammation of the tongue). Choice A is incorrect because bradycardia would not be expected in pernicious anemia, and reduced pulse is not a typical finding. Choice B is incorrect because weight gain is not a common symptom of pernicious anemia. Choice C is incorrect because angina and double vision are not typical findings of pernicious anemia, and anorexia is more likely due to other causes.

Correct Answer: C

Rationale: Rationale: 1. Abdominal injection sites have a higher blood supply, leading to faster absorption. 2. Insulin absorption is faster in areas with more blood vessels. 3. Rapid absorption at the abdomen results in quicker onset of action. 4. Other sites may have slower absorption due to less blood flow. Summary: A: Incorrect. Absorption is faster at abdominal sites due to increased blood flow. B: Incorrect. Absorption varies based on injection site blood supply. C: Correct. Abdominal injection sites have rapid insulin absorption. D: Incorrect. Insulin absorption is consistent based on blood flow at injection sites.

Correct Answer: A

Rationale: The correct answer is A: The nurse should practice interviewing strategies. This is the best remedy because improving the nurse's ability to gather comprehensive information during client history will ensure sufficient data for planning interventions. By practicing interviewing strategies, the nurse can learn to ask relevant questions, actively listen, and probe for additional details. Summary: B: Modifying the data collection tool may not address the issue of insufficient information if the problem lies with how the nurse conducts the interview. C: Determining the specific purpose of data collection is important but may not solve the immediate issue of lacking information for intervention planning. D: Updating the database is irrelevant to the problem of inadequate data collection during client history.

Correct Answer: B

Rationale: Severe and extensive hemolysis leads to the release of large amounts of hemoglobin into the bloodstream, causing hemoglobinemia. This can result in hemoglobinuria, leading to acute renal failure and ultimately shock. Shock is the correct answer as it is a severe consequence of extensive hemolysis. Leg ulcers (A) may occur in conditions like peripheral arterial disease. Priapism (C) is unrelated to hemolysis. Compromised growth (D) is not a common consequence of hemolysis.