Nursing Process 1 Test Questions

Correct Answer: A

Rationale: The correct answer is A: Post-trauma syndrome related to being attacked. This diagnosis accurately reflects the client's symptoms of reliving the traumatic event, crying uncontrollably, and expressing fear. "Post-trauma syndrome" encompasses the psychological and emotional distress following a traumatic event. Choice B: Psychological overreaction simplifies the client's experience and does not capture the severity or ongoing nature of the trauma symptoms. Choice C: Needs assistance coping with attack is vague and does not provide a specific diagnosis or acknowledge the clinical presentation of the client. Choice D: Mental distress related to being attacked is too broad and does not specify the specific syndrome or symptoms experienced by the client.

Correct Answer: A

Rationale: The correct answer is A: Rice and lean chicken. A low residue diet aims to reduce fiber intake to ease digestion. Rice and lean chicken are low in fiber and easy to digest. Pasta with vegetables (B) contains high-fiber vegetables. Strawberry pie (C) is high in fiber due to fruit and crust. Tuna casserole (D) may contain high-fiber ingredients like noodles and vegetables. Therefore, A is the best choice for a low residue diet.

Correct Answer: B

Rationale: The correct answer is B: Purplish discoloration of hands and feet. Hand-foot syndrome in sickle cell anemia is characterized by pain, swelling, and purplish discoloration of the hands and feet due to vaso-occlusive crisis. Unequal growth of fingers and toes (A), webbing between fingers and toes (C), and deformities of wrists and ankles (D) are not typical findings associated with hand-foot syndrome in sickle cell anemia.

Correct Answer: B

Rationale: The correct answer is B because it follows the SMART approach: Specific (monitor heart rhythm), Measurable (continuously this shift), Achievable (feed self at all mealtimes), Relevant (shortness of breath), and Time-bound (today). Choice A lacks specificity and measurability. Choice C focuses on the nurse's action, not patient outcomes. Choice D lacks specificity and measurability, focusing on the nurse's actions rather than patient outcomes.

Correct Answer: B

Rationale: The correct answer is B: Isolated systolic hypertension. This is because in isolated systolic hypertension, the systolic blood pressure is elevated while the diastolic blood pressure remains normal. This condition is common in older adults and is often related to aging and stiffening of the arteries. Primary hypertension (A) typically involves both elevated systolic and diastolic pressures. Secondary hypertension (C) is caused by an underlying condition. Hypertensive emergency (D) is characterized by severe elevations in both systolic and diastolic pressures with acute target organ damage.