Nursing Process 1 Test Questions

Correct Answer: D

Rationale: The correct answer is D: Administer pain medication. The priority in this situation is to address the patient's pain and provide relief. Administering pain medication will help alleviate the discomfort and enable the patient to mobilize with crutches or a walker. Walking without pain is crucial for the patient's recovery. Explanation for other choices: A: Assisting the patient to walk with crutches may worsen the pain and should not be attempted until the pain is managed. B: Obtaining a walker is not the priority as the immediate concern is addressing the patient's pain. C: Consulting physical therapy may be beneficial in the long term, but immediate pain relief is the priority in this situation.

Correct Answer: B

Rationale: Rationale: 1. Discharge planning should start at admission to ensure comprehensive preparation. 2. Early planning allows for assessment of needs and coordination of resources. 3. It promotes continuity of care and reduces risks of readmission. 4. Options A, C, and D are incorrect as they miss the opportunity for proactive planning.

Correct Answer: D

Rationale: The correct answer is D: leukocytosis. Carbamazepine can cause bone marrow suppression, leading to leukocytosis. Monitoring for elevated white blood cell count is essential to detect this potential complication early. A: Adult respiratory distress syndrome is not a common complication of carbamazepine. B: Elevated levels of phenytoin is not a direct complication of carbamazepine use. C: Diplopia is a common side effect of carbamazepine, not a potential complication like leukocytosis.

Correct Answer: B

Rationale: The correct answer is B: Focused assessment. In this scenario, the nurse is continuously monitoring specific aspects such as vital signs, pupils, and orientation at regular intervals, which is characteristic of a focused assessment. This type of assessment allows the nurse to gather specific data related to the client's condition and respond promptly to any changes. A: Initial assessment is conducted upon admission to establish baseline data. C: Time-lapsed reassessment involves comparing current data to previous assessments over a longer period. D: Emergency assessment is performed in urgent situations to quickly identify life-threatening issues. By systematically assessing the client's vital signs, pupils, and orientation at frequent intervals, the nurse can provide timely and appropriate care in the intensive care unit setting.

Correct Answer: C

Rationale: The correct answer is C: Joint abnormalities. In rheumatoid arthritis, joint abnormalities such as swelling, warmth, and tenderness are the hallmark manifestations. Assessing joint abnormalities first is crucial as they are the primary clinical signs of the disease. Muscle weakness (A) is a common symptom but typically occurs later due to joint inflammation and disuse. Painful subcutaneous nodules (B) are present in some cases but are not as common or prominent as joint abnormalities. Gait disturbances (D) may occur as a result of joint damage, but they are secondary to the primary manifestation of joint abnormalities. By prioritizing the assessment of joint abnormalities, the nurse can promptly identify and address the most prevalent disease manifestations in rheumatoid arthritis.