Nursing Process Test Questions

Correct Answer: D

Rationale: The correct answer is D: The client is experiencing a mild overdosage. Tinnitus is a common symptom of aspirin toxicity. Aspirin overdose can lead to tinnitus due to its ototoxic effects. This occurrence indicates that the client may be taking too much aspirin, resulting in toxicity. The other choices (A, B, C) are incorrect because tinnitus is not a normal side effect of aspirin working correctly, upper GI bleed, or a metallic taste in the mouth.

Correct Answer: D

Rationale: The correct answer is D. Parkinson's disease is characterized by bradykinesia, tremor, and muscle rigidity. Bradykinesia refers to slowness of movement, tremor involves involuntary shaking, and muscle rigidity causes stiffness and resistance to movement. These three symptoms are commonly known as the classic triad of Parkinson's disease. Therefore, selecting "All of the above" (D) is the correct choice as it encompasses all the key features of Parkinson's disease. Choices A, B, and C individually are incorrect because they do not fully capture the comprehensive presentation of symptoms in Parkinson's disease.

Correct Answer: A

Rationale: The correct answer is A because subjective data refers to information reported by the client, such as their symptoms or feelings. In this case, the client experiencing nausea and loss of appetite due to chemotherapy is subjective as it is based on the client's personal experience and perception. Choice B is incorrect because the client becoming teary is an observable behavior, making it an objective data point. Choice C is incorrect as the amount of effluent from the ileostomy is a measurable and quantifiable data, making it objective. Choice D is also incorrect as the patient's unwillingness to manipulate or empty his ostomy bag is an observable behavior, not based on the client's report.

Correct Answer: C

Rationale: The correct answer is C: Muscle weakness. Metolazone is a diuretic that can lead to low potassium levels, causing muscle weakness. Instructing the patient to report muscle weakness is crucial to prevent any potential serious complications. Numb hands, gastrointestinal distress, and nightmares are not commonly associated with metolazone and do not pose as immediate risks as muscle weakness does. It is essential to prioritize the most critical side effect to ensure the patient's safety and well-being.

Correct Answer: B

Rationale: The correct answer is B: Hives or rashes. In autoimmune disorders, the immune system mistakenly attacks the body's own tissues, leading to various symptoms. Hives or rashes are common manifestations of autoimmune disorders due to the immune response affecting the skin. Other choices are incorrect because hypotension is not typically associated with autoimmune disorders, localized inflammation may be present but is not specific to autoimmune disorders, and cramping and vomiting are not primary signs of autoimmune disorders.