Nursing Process Practice Questions

Correct Answer: B

Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is highly indicative of breast cancer. This finding suggests an invasive tumor pulling on the skin, causing dimpling. Other choices are incorrect because slight breast asymmetry (A) is common, bloody nipple discharge (C) can be benign or due to other conditions, and multiple freely movable masses (D) are more indicative of benign breast conditions like fibrocystic changes.

Correct Answer: C

Rationale: Correct Answer: C - ACTH Rationale: 1. ACTH (adrenocorticotropic hormone) can help control symptoms and induce remission in multiple sclerosis by reducing inflammation. 2. ACTH stimulates the production of cortisol, a natural anti-inflammatory hormone. 3. By reducing inflammation in the central nervous system, ACTH can help manage symptoms and promote remission. Summary of other choices: A: Acyclovir - Antiviral medication used to treat herpes infections, not effective for multiple sclerosis. B: Thyrotropin - Hormone that stimulates thyroid function, not used in the treatment of multiple sclerosis. D: Benadryl - Antihistamine used for allergies and itching, not indicated for multiple sclerosis management.

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: A

Rationale: The correct answer is A because it meets the goal of maintaining a heart rate of 78 beats/min. This specific date ensures the consistency of the heart rate within the desired range. Choices B, C, and D do not align with the goal as they either have a different heart rate or occur on a different date. Therefore, A is the only option that accurately reflects the goal being met on the specified date.

Correct Answer: D

Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.