Nursing Process Final Exam Questions

Correct Answer: B

Rationale: The correct answer is B: Ask the patient to return to the room, so the nurse can inspect the abdomen. Rationale: 1. Patient safety: By examining the patient's abdomen, the nurse can assess for any signs of distress or potential medical issues. 2. Patient-centered care: It is essential to prioritize the patient's well-being by addressing their concerns promptly and appropriately. 3. Professional responsibility: Nurses are trained to assess and evaluate patient symptoms to provide necessary care and support. Summary: A: Requesting the family to leave does not address the patient's symptoms and may disrupt the patient's support system. C: Asking about bowel movements and offering food may not be appropriate if the patient is experiencing stomach discomfort. D: Offering food without proper assessment may worsen the patient's condition and is not recommended before a proper evaluation.

Correct Answer: A

Rationale: The correct answer is A: It is associated with stages 1 and 2 hypertension. Smoking is a major risk factor for developing hypertension, especially stages 1 and 2. Nicotine in cigarettes can lead to vasoconstriction, increased heart rate, and overall elevated blood pressure. This information is crucial for patients to understand the direct impact of smoking on their blood pressure levels. Choice B is incorrect because smoking does indeed affect BP regulation by causing vasoconstriction and elevated heart rate. Choice C is incorrect as smoking actually causes vasoconstriction rather than vasodilation. Choice D is incorrect because smoking does lead to sustained elevation of blood pressure, especially in the long term.

Correct Answer: D

Rationale: Step 1: In HHNS, there is severe hyperglycemia leading to osmotic diuresis. Step 2: Osmotic diuresis causes loss of potassium in urine, leading to hypokalemia. Step 3: Hypokalemia is a common electrolyte imbalance in HHNS due to excessive urinary loss of potassium. Step 4: Therefore, the nurse should anticipate a below-normal serum potassium level in a client with HHNS. Summary: A: Elevated serum acetone level is seen in diabetic ketoacidosis, not HHNS. B: Serum alkalosis is not typically associated with HHNS. C: Serum ketone bodies are elevated in diabetic ketoacidosis, not HHNS.

Correct Answer: A

Rationale: The correct answer is A: fluid volume deficit related to depletion of intravascular volume. Peritonitis causes inflammation of the peritoneum, leading to fluid shifting into the peritoneal cavity, causing hypovolemia. Hypotension and tachycardia are signs of decreased intravascular volume. Rigid abdominal muscles and rebound tenderness indicate peritoneal irritation. Choice B is incorrect because elevated ammonia levels are not associated with the client's symptoms. Choice C is incorrect because increased peristalsis does not explain the client's hypotension and tachycardia. Choice D is incorrect because malabsorption does not align with the client's acute presentation of severe abdominal pain and peritonitis.

Correct Answer: D

Rationale: Step 1: Multiple sclerosis (MS) is a progressive disease affecting the central nervous system. Step 2: Axon degeneration occurs in MS, leading to impaired nerve signal transmission. Step 3: MS is characterized by sclerosed patches, or plaques, in the nervous system. Step 4: Demyelination of the brain and spinal cord is a hallmark feature of MS. Step 5: Therefore, all of the above choices are correct as they accurately describe key features of MS.