Nursing Process Practice Questions

Correct Answer: A

Rationale: The correct answer is A: Ambulating a patient. Direct care interventions involve hands-on activities directly impacting patient outcomes. Ambulating a patient is a direct care intervention as it involves physically assisting the patient to move, promoting circulation, preventing complications, and improving overall well-being. Inserting a feeding tube (B) and performing resuscitation (C) are also direct care interventions as they involve immediate patient care actions. Documenting wound care (D) is not a direct care intervention as it involves recording information about a care activity rather than physically performing the care itself.

Correct Answer: C

Rationale: Correct Answer: C - ACTH Rationale: 1. ACTH (adrenocorticotropic hormone) can help control symptoms and induce remission in multiple sclerosis by reducing inflammation. 2. ACTH stimulates the production of cortisol, a natural anti-inflammatory hormone. 3. By reducing inflammation in the central nervous system, ACTH can help manage symptoms and promote remission. Summary of other choices: A: Acyclovir - Antiviral medication used to treat herpes infections, not effective for multiple sclerosis. B: Thyrotropin - Hormone that stimulates thyroid function, not used in the treatment of multiple sclerosis. D: Benadryl - Antihistamine used for allergies and itching, not indicated for multiple sclerosis management.

Correct Answer: B

Rationale: Rationale for Correct Answer B: Rehabilitation plans for Mr. Gabatan should be considered and planned for early in his care to optimize his recovery and quality of life. Planning early allows for tailored interventions to address his specific needs and goals, promoting better outcomes. Early rehabilitation can also prevent complications and improve functional abilities. By proactively addressing rehabilitation needs, Mr. Gabatan can have a smoother transition back to his daily activities. Summary of Incorrect Choices: A: Leaving the rehabilitation plans solely up to Mr. Gabatan and his family may not consider all aspects of his recovery and could lead to suboptimal outcomes. C: Assuming that Mr. Gabatan will return to his former activities without a rehabilitation plan overlooks the individualized care needed for his recovery. D: Dismissing the need for rehabilitation based on the assumption that he may not be able to work again is premature and does not account for potential improvements in his condition through appropriate rehabilitation interventions.

Correct Answer: D

Rationale: The correct answer is D: �Your heart is not an efficient pump.� This response is the best choice as it accurately describes heart failure, which is a condition where the heart is unable to pump blood effectively. This leads to symptoms such as fatigue, shortness of breath, and fluid retention. Explanation: 1. Choice A is incorrect because heart failure does not mean the heart stops; it means the heart is not functioning properly. 2. Choice B is incorrect because heart failure does not necessarily mean there is dead muscle tissue in the heart. 3. Choice C is incorrect because heart failure is not about pumping too much blood; it is about the heart's inability to pump blood efficiently, leading to circulation problems and other symptoms.

Correct Answer: B

Rationale: The correct answer is B: Aldosterone. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and water balance in the body. It acts on the kidneys to increase reabsorption of sodium, leading to water retention and increased blood volume. This helps maintain blood pressure and electrolyte balance. A: Antidiuretic hormone (ADH) mainly acts on the kidneys to increase water reabsorption, not sodium retention. C: Thyroid hormone does not directly influence sodium retention. D: Insulin regulates blood sugar levels by promoting glucose uptake, it does not have a direct role in sodium retention.