Nursing Process Practice Questions

Correct Answer: D

Rationale: The correct answer is D: To help nurses focus on the scope of medical practice. Developing a standard formal nursing diagnosis helps nurses to identify and focus on the patient's specific health issues within the nursing scope of practice. This enables nurses to provide targeted and effective care interventions. A: To form a language that can be encoded only by nurses - This choice is incorrect because the purpose of a nursing diagnosis is not exclusive to nurses and should be comprehensible to all healthcare professionals caring for the patient. B: To distinguish the nurse�s role from the physician�s role - While this distinction is important, the main purpose of developing a nursing diagnosis is to guide nursing interventions based on the patient's nursing care needs, rather than solely differentiating roles. C: To develop clinical judgment based on other�s intuition - This choice is incorrect as clinical judgment should be based on evidence-based practice and critical thinking, rather than solely relying on intuition or others' opinions.

Correct Answer: D

Rationale: The correct answer is D: Pallor, tachycardia, and a sore tongue. Pernicious anemia is caused by a deficiency in vitamin B12, leading to symptoms such as pallor (due to decreased red blood cells), tachycardia (as the heart works harder to compensate for decreased oxygen-carrying capacity of the blood), and a sore tongue (due to inflammation of the tongue). Choice A is incorrect because bradycardia would not be expected in pernicious anemia, and reduced pulse is not a typical finding. Choice B is incorrect because weight gain is not a common symptom of pernicious anemia. Choice C is incorrect because angina and double vision are not typical findings of pernicious anemia, and anorexia is more likely due to other causes.

Correct Answer: A

Rationale: Correct Answer: A - Cerebral edema Rationale: 1. SIADH leads to water retention and dilutional hyponatremia. 2. Diuretic therapy aims to increase urine output and correct fluid imbalance. 3. If the client does not comply, excessive water retention can lead to cerebral edema. 4. Cerebral edema is a serious complication that can cause neurological deficits. Summary: - B: Severe hyperkalemia is unlikely as diuretics would help excrete excess potassium. - C: Hypovolemic shock is not expected as fluid restriction may prevent rapid volume loss. - D: Tetany is not a direct consequence of non-compliance with treatment for SIADH.

Correct Answer: B

Rationale: The correct answer is B: Re-exposure to a specific antigen. Memory cells are formed after initial exposure to an antigen. Upon re-exposure to the same antigen, memory cells quickly recognize and respond, converting into plasma cells to produce antibodies. This process is known as secondary immune response. Incorrect choices: A: An organ transplant - Organ transplant does not involve the conversion of memory cells to plasma cells. C: Release of lymphokines - Lymphokines are signaling molecules secreted by immune cells but do not directly cause memory cells to convert to plasma cells. D: Initial exposure to an antigen - Initial exposure to an antigen leads to the formation of memory cells, not their conversion to plasma cells upon re-exposure.

Correct Answer: B

Rationale: Rationale for Correct Answer B: Rehabilitation plans for Mr. Gabatan should be considered and planned for early in his care to optimize his recovery and quality of life. Planning early allows for tailored interventions to address his specific needs and goals, promoting better outcomes. Early rehabilitation can also prevent complications and improve functional abilities. By proactively addressing rehabilitation needs, Mr. Gabatan can have a smoother transition back to his daily activities. Summary of Incorrect Choices: A: Leaving the rehabilitation plans solely up to Mr. Gabatan and his family may not consider all aspects of his recovery and could lead to suboptimal outcomes. C: Assuming that Mr. Gabatan will return to his former activities without a rehabilitation plan overlooks the individualized care needed for his recovery. D: Dismissing the need for rehabilitation based on the assumption that he may not be able to work again is premature and does not account for potential improvements in his condition through appropriate rehabilitation interventions.