Nursing Process Practice Questions

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by gathering data related to the patient's current health issue or concern. This step is crucial as it helps identify the primary problem and sets the direction for further data collection and analysis. By focusing on the patient's presenting situation, the nurse can prioritize information gathering and make informed decisions about the next steps in care. Incorrect choices: A: Completing questions in chronological order may not be relevant to the patient's current issue and could lead to missing important details. C: Making accurate interpretations of the data comes after data collection, so it is not the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to gather specific information.

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.

Correct Answer: A

Rationale: The correct answer is A: Infection. After a splenectomy, the client is at risk for infection due to the spleen's role in the immune system. Without the spleen, the body's ability to fight infections is reduced. Infections can be serious and life-threatening. B: Urinary retention is not a typical complication of a splenectomy. C: Congestive heart failure is not directly related to a splenectomy. D: Viral hepatitis is not a common complication of a splenectomy.

Correct Answer: C

Rationale: The correct answer is C: Lean red meats. Lean red meats are a rich source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Heme iron helps improve iron levels more effectively in individuals with iron deficiency anemia. Fresh fruits (A) and dairy products (B) contain minimal iron, while breads and cereals (D) provide non-heme iron which is not as readily absorbed.

Correct Answer: A

Rationale: The correct answer is A: Detects the presence of malignant cells. Biopsy involves taking a sample of tissue to examine under a microscope for the presence of abnormal or cancerous cells. This procedure is crucial for diagnosing cancer accurately. Choice B (Measures hemoglobin content) is incorrect because hemoglobin content is typically measured through blood tests, not biopsies. Choice C (Measures the RBC size) is incorrect as RBC size is usually assessed through a complete blood count (CBC) test, not a biopsy. Choice D (Detects arterial occlusion) is incorrect because arterial occlusion is typically diagnosed through imaging studies like Doppler ultrasound or angiography, not through a biopsy procedure.