Nursing Process Final Exam Questions

Correct Answer: B

Rationale: The correct answer is B because before discontinuing a patient's plan of care related to physical mobility, the nurse needs to evaluate whether the patient goals and outcomes have been met. This step ensures that the patient has achieved the desired level of physical mobility improvement and is ready to safely continue their care at home. A: Determining whether the patient has transportation to get home is important but not directly related to the patient's physical mobility goals and outcomes. C: Establishing a follow-up appointment is important but does not directly address the evaluation of the patient's physical mobility improvement. D: Ensuring that the patient's prescriptions are filled is crucial for medication management but does not specifically evaluate the patient's physical mobility progress.

Correct Answer: D

Rationale: The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions." Rationale: 1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being. 2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery. 3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient. 4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes. Summary: A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs. B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses. C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.

Correct Answer: B

Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is a classic sign of breast cancer. This finding is concerning as it indicates an abnormal growth that has invaded surrounding tissues. Dimpling occurs due to fibrotic changes pulling on the skin. Choices A, C, and D are incorrect. A slight asymmetry of the breasts is common and not necessarily indicative of cancer. Bloody discharge from the nipple can be a sign of other conditions like intraductal papilloma. Multiple firm, round, freely movable masses that change with the menstrual cycle are likely benign fibrocystic changes.

Correct Answer: C

Rationale: The correct answer is C: bacteria. Hepatitis is primarily caused by viruses (such as Hepatitis A, B, C), toxins (like alcohol or certain medications), and chemicals/drugs. Bacteria do not typically cause hepatitis as it is a viral infection that affects the liver. Therefore, choice C is the exception among the listed causes. Viruses directly target liver cells, toxins can damage the liver, and certain chemicals/drugs can lead to liver inflammation. Hence, bacteria do not play a significant role in causing hepatitis.

Correct Answer: C

Rationale: The correct answer is C: deposits of adipose tissue in the trunk and dorsocervical area. In Cushing's syndrome, there is excess cortisol production leading to central obesity with fat accumulation in the trunk and dorsocervical area (buffalo hump). This is due to cortisol's role in redistributing fat. A: hypotension is incorrect because individuals with Cushing's syndrome typically have hypertension due to the effects of excess cortisol on blood pressure regulation. B: thick, coarse skin is incorrect as individuals with Cushing's syndrome may have thin, fragile skin due to decreased collagen formation. D: weight gain in arms and legs is incorrect as the weight gain in Cushing's syndrome tends to be centralized in the trunk and face rather than the extremities.