Nursing Process 1 Test Questions

Correct Answer: B

Rationale: The correct answer is B: Purplish discoloration of hands and feet. Hand-foot syndrome in sickle cell anemia is characterized by pain, swelling, and purplish discoloration of the hands and feet due to vaso-occlusive crisis. Unequal growth of fingers and toes (A), webbing between fingers and toes (C), and deformities of wrists and ankles (D) are not typical findings associated with hand-foot syndrome in sickle cell anemia.

Correct Answer: D

Rationale: The correct answer is D: Loss of peripheral vision. Macular degeneration affects the central vision, specifically the macula, which is responsible for central vision and sharp detail. Loss of peripheral vision is not a typical symptom of macular degeneration. The macula is located in the center of the retina, so symptoms would relate to central vision impairments such as decreased ability to distinguish colors, loss of central vision, and loss of near vision. Peripheral vision is not primarily affected by macular degeneration, hence it is not an expected symptom.

Correct Answer: A

Rationale: Correct Answer: A (Independent intervention) Rationale: 1. Independent interventions are actions that nurses can initiate without a doctor's order. 2. Teaching a client how to administer insulin falls under the scope of nursing practice. 3. Nurses have the knowledge and authority to educate clients on self-care management. 4. This intervention does not require collaboration with other healthcare providers. Summary: B: Dependent interventions require a doctor's order. C: Interdependent interventions involve collaboration with other healthcare providers. D: Collaborative interventions involve working with other healthcare professionals.

Correct Answer: B

Rationale: The correct answer is B because it follows the SMART approach: Specific (monitor heart rhythm), Measurable (continuously this shift), Achievable (feed self at all mealtimes), Relevant (shortness of breath), and Time-bound (today). Choice A lacks specificity and measurability. Choice C focuses on the nurse's action, not patient outcomes. Choice D lacks specificity and measurability, focusing on the nurse's actions rather than patient outcomes.

Correct Answer: D

Rationale: The correct answer is D: Polyps. Polyps in the colon are precancerous growths that can develop into colorectal cancer over time. Identifying polyps during a medical history interview can raise suspicion for colorectal cancer due to their potential to progress into malignancy. Duodenal ulcer (A) is not directly related to colorectal cancer. Weight gain (B) is a non-specific symptom and does not specifically indicate colorectal cancer. Hemorrhoids (C) are common and usually benign, not directly linked to colorectal cancer.