Nursing Process Final Exam Questions

Correct Answer: C

Rationale: The correct answer is C: Counselling on alternate therapies. Chronic tension headaches may be exacerbated by stress or other psychological factors, making counseling an appropriate intervention. The nurse can explore relaxation techniques, stress management strategies, or cognitive-behavioral therapy to help the client manage their headaches. A: Instructing the client to monitor for signs of bruising or bleeding is unrelated to tension headaches and not a priority in this situation. B: Suggesting eating and swallowing techniques that reduce the potential for aspiration is not relevant to tension headaches and is not the most appropriate intervention. D: Advising the client to change sleeping positions frequently may help with other types of headaches but is not the most effective strategy for managing chronic tension headaches.

Correct Answer: B

Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because: A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression. C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding. D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.

Correct Answer: B

Rationale: The correct answer is B because emphysema is characterized by the destruction of the alveoli walls, leading to a loss of elasticity in the lungs. This results in air becoming trapped in the lungs, making it difficult to exhale properly. Explanation for why the other choices are incorrect: A: Inflamed bronchioles causing secretions describe bronchitis, not emphysema. C: Damage to the blood supply isn't a primary feature of emphysema; it's more about lung tissue destruction. D: Large dilated sacs of sputum in the lungs is not an accurate description of emphysema; it's more related to bronchiectasis.

Correct Answer: B

Rationale: The correct answer is B: Drowsiness. Muscle relaxants can cause drowsiness as a common side effect due to their sedative properties. This can impair alertness and coordination, so it's crucial for the patient to be aware of this potential effect. Choice A, hypoglycemia, is not typically associated with muscle relaxants. Choice C, hypotension, is more commonly linked to medications like antihypertensives. Choice D, dyspnea, which is difficulty breathing, is not a common side effect of muscle relaxants. Therefore, the nurse should primarily focus on educating the patient about the potential side effect of drowsiness.

Correct Answer: B

Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is a classic sign of breast cancer. This finding is concerning as it indicates an abnormal growth that has invaded surrounding tissues. Dimpling occurs due to fibrotic changes pulling on the skin. Choices A, C, and D are incorrect. A slight asymmetry of the breasts is common and not necessarily indicative of cancer. Bloody discharge from the nipple can be a sign of other conditions like intraductal papilloma. Multiple firm, round, freely movable masses that change with the menstrual cycle are likely benign fibrocystic changes.