Nursing Process Practice Questions

Correct Answer: A

Rationale: Rationale: A: Pressing the system in place for 30 to 60 seconds helps ensure proper adhesion and absorption of the medication. This step is crucial for the effectiveness of the pain management system. B: Choosing a site on the lower torso is not necessary for applying the system. The site selection should be based on guidelines and patient preference. C: Shaving the application site is not recommended unless specifically indicated. It is not a standard step for applying a pain management system. D: Applying the system immediately after removal from a package may not allow the adhesive to fully activate, affecting its efficacy. It is important to follow the recommended steps for proper application.

Correct Answer: D

Rationale: The correct answer is D because developing a formal nursing diagnosis helps nurses focus on their scope of practice, which includes identifying and addressing the patient's nursing care needs. By formulating a clear nursing diagnosis, nurses can prioritize interventions that are within their domain of expertise. This ensures efficient and effective patient care delivery. A: Incorrect. Developing a nursing diagnosis is not about creating a language exclusive to nurses; it is about identifying patient care needs. B: Incorrect. While nursing diagnoses do delineate the nurse's role, the primary purpose is not to distinguish it from the physician's role. C: Incorrect. Nursing diagnoses are based on evidence and critical thinking, not solely on intuition or others' judgments.

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.

Correct Answer: B

Rationale: Step-by-step rationale: 1. Metabolic acidosis is characterized by low pH and low plasma bicarbonate. 2. In this condition, there is an excess of acids or a loss of bicarbonate. 3. The kidneys are unable to adequately excrete acids or retain bicarbonate. 4. This leads to a decrease in bicarbonate levels and a decrease in pH. 5. Respiratory acidosis (A) is characterized by low pH and high CO2 levels. 6. Respiratory alkalosis (C) is characterized by high pH and low CO2 levels. 7. Metabolic alkalosis (D) is characterized by high pH and high bicarbonate levels. Summary: - Choice A is incorrect as it describes a condition with high CO2 levels. - Choice C is incorrect as it describes a condition with high pH. - Choice D is incorrect as it describes a condition with high bicarbonate levels. - Choice B is correct as it accurately describes the characteristics of a condition with low pH

Correct Answer: B

Rationale: The correct answer is B because providing frequent mouth care to Mr. Franco helps in removing dried blood when his tongue is bitten during a seizure, preventing infection and promoting oral hygiene. This is crucial in preventing complications and ensuring Mr. Franco's overall well-being. Choice A is incorrect because thirst is not directly related to mouth care, and increasing fluids intake would address dehydration more effectively. Choice C is incorrect as tactile stimulation may not necessarily hasten return to consciousness in this context. Choice D is incorrect as it refers to a different issue related to mouth breathing in comatose patients, which is not the immediate concern addressed by frequent mouth care in this scenario.