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: The correct response is C: �Would you like to meet with your family and your physician about this matter?� Rationale: 1. Involving the family and physician ensures a collaborative decision-making process. 2. It respects the client's autonomy and involves them in the decision-making process. 3. It promotes open communication and support from loved ones. 4. It addresses the client's concerns about continuing treatment based on family wishes. Summary: A: Refers to psychological support, but the client's primary concern is medical treatment decisions. B: Involves religious support, which may not align with the client's beliefs or address the medical decision. D: Acknowledges the client's feelings but lacks a collaborative approach involving family and healthcare team.

Correct Answer: B

Rationale: The correct answer is B: Disturbed body image. The client expressing concern about the external fixation device making his leg look ugly indicates a disturbance in how he perceives his body image. This can lead to feelings of low self-esteem and impact his overall psychological well-being. Impaired physical mobility (A) is not the priority as the concern is not related to limitations in movement. Risk for infection (C) may be a potential risk with the device but is not directly related to the client's current concern. Risk for social isolation (D) is not directly indicated by the client's statement about the appearance of the leg. Therefore, the most appropriate nursing diagnosis is Disturbed body image (B) based on the client's expressed concern.

Correct Answer: B

Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is highly indicative of breast cancer. This finding suggests an invasive tumor pulling on the skin, causing dimpling. Other choices are incorrect because slight breast asymmetry (A) is common, bloody nipple discharge (C) can be benign or due to other conditions, and multiple freely movable masses (D) are more indicative of benign breast conditions like fibrocystic changes.

Correct Answer: D

Rationale: The correct answer is D because developing a standard formal nursing diagnosis helps nurses focus on the scope of their practice. By identifying specific patient problems and their potential causes, nurses can provide appropriate interventions and evaluate patient outcomes effectively. This process enhances the quality of care delivery and promotes patient safety. A: This is incorrect because nursing diagnoses are not meant to be a language exclusive to nurses but rather a standardized way to communicate patient data. B: This is incorrect as nursing diagnoses are not about distinguishing roles but rather about identifying and addressing patient problems. C: This is incorrect as nursing diagnoses are based on evidence and critical thinking, not solely on intuition.