Nursing Process Test Questions

Correct Answer: A

Rationale: The correct answer is A: 11mg/dl. This patient is likely experiencing hypocalcemia, indicated by positive Trousseau's and Chvostek's signs. These signs suggest neuromuscular irritability due to low calcium levels. A serum calcium level of 11mg/dl is higher than normal, indicating possible hyperparathyroidism causing high calcium levels. Choices B, C, and D are lower than normal, which would exacerbate symptoms rather than alleviate them.

Correct Answer: C

Rationale: The correct answer is C because it does not provide a specific, measurable outcome. It is vague and subjective, making it difficult to assess and track progress. In contrast, choices A, B, and D are all specific, measurable, and time-bound goals, making them more effective for evaluating client outcomes. Choice A specifies the amount of fluid intake and the time frame, choice B sets a clear deadline for demonstrating a skill, and choice D outlines a specific task to be completed upon discharge. Therefore, C is the correct answer as it lacks the clear criteria needed for effective outcome evaluation.

Correct Answer: B

Rationale: The correct answer is B. A semiprivate room with one or two consistent caregivers is the most therapeutic setting for an agitated head-injured patient. Here's the rationale: 1. Consistency: Having one or two consistent caregivers provides the patient with a stable and familiar environment, which can help reduce agitation. 2. Privacy: A semiprivate room offers more privacy compared to a day room or a ward, which can help minimize external stimuli and promote relaxation. 3. Individualized care: In a semiprivate room, caregivers can focus more on the specific needs of the patient, leading to better management of agitation. 4. Reduced distractions: Being in a semiprivate room minimizes distractions and noise, which can be overwhelming for an agitated head-injured patient. Summary: A, C, and D are incorrect because they do not offer the same level of consistency, privacy, individualized care, and reduced distractions as a semiprivate room with one

Correct Answer: C

Rationale: The correct answer is C: Thyroid crisis. These signs suggest thyroid storm, a life-threatening complication of thyroid surgery. The high fever, tachycardia, and restlessness are classic symptoms. Thyroid crisis can lead to severe complications if not managed promptly. A: Diabetic ketoacidosis typically presents with polyuria, polydipsia, and fruity breath odor. B: Hypoglycemia would present with symptoms like diaphoresis, tremors, and confusion. D: Tetany is associated with hypocalcemia and presents with muscle cramps, spasms, and numbness.

Correct Answer: D

Rationale: The correct answer is D: Dependent. In this scenario, the nurse is administering pain medication based on a healthcare provider's prescription, which demonstrates a dependent nursing intervention. The nurse is reliant on the provider's order to carry out this action. Collaborative interventions involve working with other healthcare professionals, independent interventions are actions that nurses can initiate without supervision, and interdependent interventions involve mutual goal-setting and decision-making among healthcare team members.