Nursing Process Practice Questions

Correct Answer: A

Rationale: The correct answer is A: Detects the presence of malignant cells. Biopsy involves taking a sample of tissue to examine under a microscope for the presence of abnormal or cancerous cells. This procedure is crucial for diagnosing cancer accurately. Choice B (Measures hemoglobin content) is incorrect because hemoglobin content is typically measured through blood tests, not biopsies. Choice C (Measures the RBC size) is incorrect as RBC size is usually assessed through a complete blood count (CBC) test, not a biopsy. Choice D (Detects arterial occlusion) is incorrect because arterial occlusion is typically diagnosed through imaging studies like Doppler ultrasound or angiography, not through a biopsy procedure.

Correct Answer: C

Rationale: The correct answer is C: fluid volume deficit. In diabetes insipidus, there is an excessive amount of dilute urine excreted, leading to dehydration and fluid volume deficit. The posterior pituitary tumor causes a deficiency in antidiuretic hormone (ADH), which regulates water reabsorption in the kidneys. As a result, the client experiences polyuria and polydipsia, leading to fluid volume deficit. Choices A, B, and D are incorrect because diabetes insipidus does not cause fluid volume excess, incontinence, or diarrhea. The key is to recognize the pathophysiology of diabetes insipidus and its impact on fluid balance.

Correct Answer: D

Rationale: The correct answer is D because developing a standard formal nursing diagnosis helps nurses focus on their scope of practice, which involves identifying and addressing the patient's nursing care needs. By formulating a specific nursing diagnosis, nurses can prioritize interventions and provide individualized care. Choice A is incorrect as nursing diagnoses are not exclusive to nurses. Choice B is incorrect because nursing and physician roles overlap. Choice C is incorrect as clinical judgment should be based on evidence and critical thinking, not solely on intuition.

Correct Answer: C

Rationale: The correct answer is C: Implementation. In this step of the nursing process, the nurse is carrying out the care plan based on the identified nursing diagnoses. The nurse is actively providing care and interventions to meet the patient's needs. Assessment (A) is the initial step where data is collected and analyzed. Planning (B) is where goals and interventions are determined based on assessment findings. Evaluation (D) is the final step where the nurse assesses the effectiveness of the care provided. In this scenario, the nurse has already completed the care plan and is now executing the plan by implementing the interventions, making choice C the correct answer.

Correct Answer: A

Rationale: The correct answer is A: Anticipatory grieving. This nursing diagnosis is appropriate because the client's symptoms, such as weight loss, fatigue, and diagnosis of gallbladder cancer, indicate a serious health condition that may lead to emotional distress. Anticipatory grieving involves feelings of loss and sadness related to an anticipated loss, such as the diagnosis of cancer. The client may experience fear, anxiety, and sadness due to the potential impact of the illness on their life. Choice B (Disturbed body image) is incorrect because the client's symptoms are more indicative of a serious health concern rather than body image issues. Choice C (Impaired swallowing) is incorrect as the symptoms described do not suggest difficulty with swallowing. Choice D (Chronic low self-esteem) is also incorrect as the symptoms are more likely related to physical health issues rather than self-esteem concerns.