Nursing Process Exam Questions

Correct Answer: A

Rationale: The correct answer is A because asthma is characterized by inflammation and bronchoconstriction of the airways, leading to difficulty breathing. This explanation accurately describes the pathophysiology of asthma. Explanation for other choices: B: Fluid in the lungs is more indicative of conditions like pneumonia or pulmonary edema, not asthma. C: Asthma involves airway constriction and inflammation, not stretching and non-functionality. D: Asthma is not caused by infection but rather triggered by factors like allergens or irritants.

Correct Answer: A

Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect rather than depression. The nurse should be culturally sensitive and understand that different cultures have varying communication norms. By considering cultural differences, the nurse can build rapport and trust with the patient. Asking the patient to make eye contact (B) may be perceived as disrespectful and may hinder effective communication. Continuing with the interview and assuming depression (C) without further assessment is premature and may lead to misdiagnosis. Notifying the health care provider for a psychological evaluation (D) is not necessary at this stage as the behavior observed may be culturally influenced.

Correct Answer: A

Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness, rather than an indication of depression or dishonesty. By understanding and respecting cultural norms, the nurse can build rapport and trust with the patient. This approach promotes effective communication and a positive patient-provider relationship. Option B is incorrect because forcing the patient to make eye contact may make her uncomfortable and hinder the therapeutic relationship. Option C is incorrect because assuming the patient is depressed based on cultural differences is inappropriate and may lead to misdiagnosis. Option D is incorrect because jumping to recommendations for a psychological evaluation without considering cultural differences first can be stigmatizing and unnecessary.

Correct Answer: C

Rationale: The correct answer is C: Reassess the patient's pain level in 30 minutes. This is the priority action as it allows the nurse to evaluate the effectiveness of the acetaminophen in relieving the patient's headache. By reassessing the pain level, the nurse can determine if the medication is working or if further intervention is needed. A: Eliminating the headache from the care plan is not appropriate as the patient's comfort and pain relief should be a priority. B: Directing the nursing assistive personnel to inquire if the headache is relieved is not thorough assessment and does not provide direct evaluation of the patient's pain level. D: Revising the plan of care may be necessary based on the reassessment, but it is not the immediate priority compared to evaluating the patient's response to treatment.

Correct Answer: C

Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.