Nursing Process Final Exam Questions

Correct Answer: C

Rationale: The correct answer is C: Health promotion. The nurse wrote a diagnosis of Readiness for enhanced urinary elimination, which indicates the patient's willingness to improve their urinary elimination abilities. Health promotion diagnoses focus on improving the client's well-being and enhancing their health potential. In this scenario, the patient's desire to learn self-catheterization aligns with health promotion as it involves empowering the patient to take an active role in their care. Choice A (Risk) is incorrect because the patient is not currently at risk for urinary elimination issues, but rather seeking to enhance their abilities. Choice B (Problem focused) is incorrect as the diagnosis is not about addressing a current problem but rather focusing on potential improvement. Choice D (Collaborative problem) is incorrect as it does not involve collaboration between healthcare providers but rather focuses on the patient's readiness and willingness to enhance their own health outcomes.

Correct Answer: A

Rationale: The correct answer is A: Measure the client�s oral temperature. This is the best follow-up because it directly assesses the client's body temperature, providing objective data to confirm the presence of fever. It is essential to gather accurate information to guide appropriate interventions. Asking a colleague for assistance (B) may not address the immediate need for temperature assessment. Giving the client a clean gown and warm blankets (C) may provide comfort but does not address the need for temperature measurement. Obtaining an order for blood cultures (D) is not the initial priority when the client is showing signs of fever; temperature measurement is the first step in assessing the client's condition.

Correct Answer: D

Rationale: The correct answer is D: Hyperosmolar solutions used primarily to reverse negative nitrogen balance. Rationale: 1. Hyperalimentation solutions are designed to provide essential nutrients intravenously. 2. Hyperosmolar solutions have a higher osmolarity compared to body fluids, providing concentrated nutrition. 3. Negative nitrogen balance occurs when the body breaks down more protein than it synthesizes, requiring additional protein intake. 4. Hyperosmolar solutions can provide adequate protein and nutrients to reverse negative nitrogen balance. Summary: A: Hypotonic solutions do not increase osmotic pressure, but rather decrease it. B: Hypertonic solutions are not primarily used for hydration in this context. C: Alkalizing solutions are not the primary purpose of hyperalimentation and do not directly address cellular sweating.

Correct Answer: A

Rationale: The correct answer is A: Adrenal cortex. Primary hyperaldosteronism is a condition where the adrenal cortex produces too much aldosterone hormone, leading to hypertension. The adrenal medulla secretes adrenaline and noradrenaline, not aldosterone, making option B incorrect. The pancreas secretes insulin and glucagon, not aldosterone, making option C incorrect. Option D is incorrect because the adrenal cortex is responsible for aldosterone secretion in primary hyperaldosteronism.

Correct Answer: C

Rationale: Step 1: Hyponatremia is an electrolyte imbalance characterized by low sodium levels in the blood. Step 2: Restricting fluid intake helps prevent further dilution of sodium in the blood, aiding in correcting hyponatremia. Step 3: Administering sodium can lead to rapid correction, risking osmotic demyelination syndrome. Step 4: Choice C is correct as it aligns with the goal of managing hyponatremia by preventing fluid overload symptoms. Summary: A, B, and D are incorrect as they do not directly address the primary concern of correcting low sodium levels in hyponatremia.