Nursing Process Exam Questions

Correct Answer: C

Rationale: The correct answer is C: Romberg�s test. Romberg�s test assesses a patient's ability to maintain balance with eyes closed, relying on proprioception from the lower limbs. A lumbar injury can affect proprioception, leading to impaired balance. Rhine�s test evaluates auditory function, not affected by a lumbar injury. Pupillary reaction assesses cranial nerve function, unrelated to a lumbar injury. The patellar reflex is a deep tendon reflex, primarily involving the spinal cord segments L2-L4, not directly affected by a lumbar injury.

Correct Answer: B

Rationale: The correct answer is B because a Snellen chart reading of 20/80 means the patient can see at 20 feet what a normal eye can see at 80 feet. This indicates that the patient's vision is below average. Choice A is incorrect because it reverses the numerator and denominator. Choice C is incorrect because it does not accurately represent the Snellen chart findings. Choice D is incorrect because 20/80 is not considered normal vision.

Correct Answer: A

Rationale: Step 1: Recognize cultural differences in communication styles. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness. Step 2: Understand that the patient's behavior may not indicate depression but rather a cultural norm. Step 3: Adjust communication approach by respecting the patient's cultural preferences. Step 4: Building trust and rapport by acknowledging and accommodating cultural differences. Summary: Choice A is correct as it acknowledges and respects cultural differences. Choices B, C, and D are incorrect as they do not consider cultural aspects and may lead to misinterpretation and inappropriate actions.

Correct Answer: C

Rationale: Rationale: - Paraplegia refers to paralysis of the lower extremities. - The prefix "para-" means alongside or beside, indicating lower body involvement. - Option A is incorrect as it refers to quadriplegia. - Option B is incorrect as it refers to quadriplegia. - Option D is incorrect as it refers to hemiplegia.

Correct Answer: C

Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.