Fundamentals of Nursing Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. This involves analyzing assessment data, utilizing critical thinking skills to identify patient problems, and formulating nursing diagnoses. Diagnostic reasoning is the process of synthesizing information to make clinical judgments and determine appropriate interventions. A: Assigning clinical cues - Incorrect. This refers to identifying observable signs or symptoms, not the process of developing a nursing diagnosis. B: Defining characteristics - Incorrect. This term is often used to describe the symptoms or manifestations associated with a nursing diagnosis, not the process of deriving the diagnosis. D: Diagnostic labeling - Incorrect. This is the final step in the nursing diagnosis process where the nurse assigns a label to the identified patient problem, not the process of critical thinking and data analysis.

Correct Answer: C

Rationale: The correct answer is C: Tears and F: Breastmilk. HIV transmission has been established through breastmilk due to the presence of the virus in the milk. Tears can also transmit HIV if they contain blood from an HIV-positive individual. Saliva, sweat, and urine do not typically contain enough HIV to transmit the virus. Blood is a well-known mode of HIV transmission due to the high viral load present in blood. Therefore, choices A, B, D, and G are incorrect as they do not have sufficient levels of the virus to transmit HIV.

Correct Answer: A

Rationale: The correct answer is A: Human Needs (Maslow) model. The nurse is using a systematic approach based on Maslow's Hierarchy of Needs, which includes physiological, safety, love/belonging, esteem, and self-actualization needs. This model organizes assessment data by prioritizing these universal life requirements. Incorrect choices: B: Functional Health Patterns model - This model focuses on 11 functional health patterns, not the hierarchy of universal life requirements. C: Human Response Patterns model - This model focuses on the individual's response to stressors, not prioritizing universal life requirements. D: Body System model - This model focuses on assessing specific body systems, not the holistic approach of addressing all life requirements.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to directly gather patient data through observation, palpation, percussion, and auscultation. It helps in assessing the patient's overall health status, identifying any abnormalities, and establishing a baseline for further care. Reviewing literature (A) helps in evidence-based practice but does not directly collect patient data. Checking orders for tests (B) and ordering medications (D) involve actions based on data collected rather than collecting the data itself.

Correct Answer: D

Rationale: The correct answer is D: throbbing headache. Nitroglycerin is a vasodilator that relaxes blood vessels, leading to increased blood flow and reduced workload on the heart. One common side effect of nitroglycerin is a throbbing headache due to the dilation of blood vessels in the brain. This side effect is expected and usually diminishes with continued use. Explanation of other choices: A: High blood pressure - Nitroglycerin actually helps lower blood pressure by dilating blood vessels. B: GIT irritation - This is not a common side effect of nitroglycerin, as it primarily affects the cardiovascular system. C: Shortness of breathing - This is not a typical side effect of nitroglycerin, as it does not directly affect respiratory function.