Nursing Process Test Bank

Correct Answer: C

Rationale: The correct answer is C because it shows a positive self-perception and self-acceptance. By choosing the dress based on how it complements her eyes, the patient demonstrates a focus on her own preferences and self-image rather than external validation or criticism. This indicates progress towards accepting her body image. A: Choice A indicates concern about others' opinions, which shows a lack of self-assurance and reliance on external validation. B: Choice B reflects negative body image and self-criticism, indicating a lack of acceptance. D: Choice D is focused on a future event, suggesting avoidance or delay in addressing the current body image issues.

Correct Answer: B

Rationale: The correct answer is B because conducting the interview in a quiet environment, such as the waiting area with the television turned off, minimizes background noise and distractions for a patient with a hearing deficit. This setting allows for better communication and ensures that the patient can hear and understand the nurse clearly. A: Conducting the interview in the patient's room with the door closed may still have background noise from the hallway or other rooms. C: Conducting the interview before administration of pain medication is not relevant to improving communication for a patient with a hearing deficit. D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional noise and distractions, making it difficult for the patient to focus on the conversation.

Correct Answer: B

Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, which are signs and symptoms that support the diagnosis. This helps to differentiate it from other types of diagnoses such as risk, possible, or wellness diagnoses. Risk nursing diagnoses predict potential problems, possible nursing diagnoses lack sufficient data for validation, and wellness diagnoses focus on promoting health rather than addressing current health issues. Therefore, only the actual nursing diagnosis is confirmed by the presence of observable defining characteristics.

Correct Answer: B

Rationale: The correct answer is B: Altered level of consciousness. This is crucial as it can indicate various underlying health issues affecting Mr. Reyes. Assessing for this helps in detecting potential neurological, metabolic, or cardiac issues. A: Decreased carotid pulses - While important, it is not as critical as altered level of consciousness in this scenario. C: Bleeding from oral cavity - This is important to address but does not take priority over assessing Mr. Reyes' level of consciousness. D: Absence of deep tendon-reflexes - This is more specific to neurological assessments and may not be as urgent as assessing his level of consciousness.

Correct Answer: B

Rationale: The correct answer is B because conducting the interview in a quiet environment, like the waiting area with the television turned off, reduces background noise and distractions for the patient with a hearing deficit. This allows for better communication and understanding. A: Conducting the interview in the patient's room with the door closed may still have distractions or noise from outside the room. C: Conducting the interview in the patient's room before administration of pain medication does not address the issue of reducing background noise for better communication. D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional distractions and noise, making it harder for the patient with a hearing deficit to communicate effectively.