Nursing Process Final Exam Questions

Correct Answer: C

Rationale: The correct answer is C: Health promotion. In this scenario, the nurse identified the patient's desire to enhance urinary elimination abilities through self-catheterization, indicating a readiness for positive change. Health promotion diagnoses focus on improving well-being and enhancing quality of life. This diagnosis supports the patient's proactive approach to managing their condition. Incorrect choices: A: Risk - This diagnosis would be used if the patient was at risk for complications related to urinary elimination, not actively seeking to improve it. B: Problem focused - This type of diagnosis would be used if the patient was experiencing issues with urinary elimination that needed to be addressed. D: Collaborative problem - This diagnosis would involve identifying a problem that requires collaboration between healthcare professionals to resolve, which is not the case in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Reduced sneezing. Decongestants work by constricting blood vessels in the nasal passages, reducing swelling and congestion, which in turn can lead to a decrease in sneezing. Increased salivation (choice A) is not a typical effect of decongestants. Increased tearing (choice C) is more commonly associated with allergies or irritants. Headache (choice D) can be a side effect of decongestants due to their impact on blood vessels, but it does not necessarily indicate effectiveness in treating allergic rhinitis.

Correct Answer: C

Rationale: The correct answer is C: Take piroxicam with food or oral antacid. This instruction helps to reduce GI irritation by providing a protective barrier for the stomach lining. Piroxicam is known to cause GI upset due to its effect on prostaglandin synthesis. Taking it with food or an antacid can help minimize this side effect. Choice A (Space the administration every 4 hours) does not address the issue of GI irritation and is not a recommended strategy for preventing this side effect. Choice B (Use the drug for a short time only) is not a direct intervention to prevent GI upset and does not provide guidance on how to manage the side effect when taking the medication. Choice D (Decrease the piroxicam dosage) may not be necessary if the client can manage the side effects with the simple intervention of taking it with food or an antacid.

Correct Answer:

Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: After setting the agenda, the nurse should proceed by asking about the patient's chief concerns or problems to gather relevant information and focus the interview on the patient's needs. This step helps establish rapport and ensures the patient is actively involved in the conversation. Incorrect Choices: A: Beginning with introductions is important, but after setting the agenda, it is more crucial to address the patient's concerns. C: Explaining that the interview will be over in a few minutes is not appropriate as it may rush the patient and hinder open communication. D: Telling the patient about administering medications in 1 hour is not relevant at this stage and does not address the patient's immediate needs.

Correct Answer: A

Rationale: The correct answer is A: 25 g/day, initially. In this scenario, the client with Hashimoto's thyroiditis and a history of cardiac issues requires a cautious approach due to the risk of exacerbating cardiac conditions with thyroid hormone replacement. Starting with a low dose of 25 �g/day allows for careful monitoring of the client's response and prevents potential adverse effects on the cardiovascular system. Summary: B: Delayed until after thyroid surgery - Not appropriate as the client requires thyroid replacement therapy for Hashimoto's thyroiditis. C: 100 �g/day, initially - Too high of an initial dose and may lead to adverse cardiovascular effects. D: Initiated before thyroid surgery - Not relevant to the client's situation as there is no indication for thyroid surgery mentioned in the question.