Nursing Process Practice Questions

Correct Answer: B

Rationale: The correct answer is B: Pupil responses. During an ophthalmic assessment, observing pupil responses is crucial as it provides information on the function of the cranial nerves and potential neurological issues. Pupil size, shape, symmetry, and reaction to light are key indicators of eye health. A: Level of central vision - While important, assessing the level of central vision is typically done by the ophthalmologist and not within the scope of the nurse's role in a routine assessment. C: External eye appearance - Although external eye appearance can give some clues about eye health, it is not as direct and crucial as observing pupil responses. D: Eye movements - While eye movements can provide information on ocular motor function, it is not as critical as assessing pupil responses in an ophthalmic assessment.

Correct Answer: A

Rationale: The correct initial action for the nurse to take is A: Try to have the client breathe slower. This is because the client may be experiencing respiratory distress, and slowing down their breathing can help improve oxygenation. Giving O2 via nasal cannula (B) should be considered if the client's oxygen saturation is low after trying to slow down their breathing. Administering sodium bicarbonate (C) is not the appropriate initial action unless the client is experiencing severe acidosis. Monitoring the client's fluid balance (D) is important but not the best initial action in this scenario where respiratory distress is the concern.

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: 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: A

Rationale: The correct answer is A: Denial. The client's refusal to accept the diagnosis of diabetes mellitus, stating that no one in their family has had it, indicates denial as a coping mechanism. Denial is a defense mechanism where individuals refuse to acknowledge unpleasant realities. In this case, the client is rejecting the diagnosis to avoid facing the reality of having a chronic condition. The other choices (B: Anger, C: Withdrawal, D: Resolution) do not fit the client's response in this scenario. Anger involves expressing frustration or hostility, withdrawal is avoiding the situation, and resolution is accepting and dealing with the issue.