Nursing Process 1 Test Questions

Correct Answer: B

Rationale: The correct answer is B because decorticate posturing is characterized by the flexion of elbows, wrists, and fingers, extension of elbows and knees, plantar flexion of feet. This pattern indicates damage to the cerebral hemispheres or internal structures of the brain. In contrast, option A describes decerebrate posturing, which indicates more severe brain damage. Option C is incorrect as it describes a mixed pattern of posturing. Option D is also incorrect as it describes a different type of posturing called decerebrate posturing.

Correct Answer: D

Rationale: The correct answer is D because monitoring for signs of infection, air embolus, and leakage/puncture are crucial in caring for a patient with a central venous line to prevent serious complications. Infections can lead to sepsis, air embolus can cause respiratory distress, and leakage/puncture can result in hemorrhage or damage to surrounding tissues. A: While a complete blood count and electrolytes may be important for monitoring the patient's overall health, they are not specific to the central venous line care. B: Regular chest x-rays are not necessary unless there are specific indications of line malposition or complications. C: Continuous infusion at a keep-vein-open rate is a standard practice but does not address the critical aspects of central line care mentioned in option D. Therefore, monitoring for signs of infection, air embolus, and leakage/puncture is the most essential component of the plan of care for a patient with a central venous line.

Correct Answer: D

Rationale: The correct answer is D, assess vital signs, as it is crucial to monitor the client's hemodynamic stability and response to treatment during the critical initial 24 hours of Addisonian crisis. Vital signs such as blood pressure, heart rate, and respiratory rate provide valuable information about the client's condition and response to therapy. Weighing the client (choice A) and testing urine for ketones (choice C) may be important but not as immediately critical as monitoring vital signs. Administering oral hydrocortisone (choice B) is essential for treatment but does not require frequent administration within the first 24 hours.

Correct Answer: A

Rationale: The correct answer is A because it encourages the novice nurse to independently observe the situation with a peer, validate the data, and discuss afterward. This approach promotes reflection, peer learning, and validation of collected data, which are essential for learning and growth. It allows the nurse to self-assess and correct errors through discussion and feedback. Choice B is incorrect as it does not address the need for validation and peer feedback. Choice C is incorrect as repeating the same mistake without guidance does not promote learning. Choice D is incorrect as meeting with the nurse manager may not provide the same level of peer learning and validation as observing with a peer.

Correct Answer: B

Rationale: The correct answer is B: Focused assessment. In this scenario, the nurse is continuously monitoring specific aspects such as vital signs, pupils, and orientation at regular intervals, which is characteristic of a focused assessment. This type of assessment allows the nurse to gather specific data related to the client's condition and respond promptly to any changes. A: Initial assessment is conducted upon admission to establish baseline data. C: Time-lapsed reassessment involves comparing current data to previous assessments over a longer period. D: Emergency assessment is performed in urgent situations to quickly identify life-threatening issues. By systematically assessing the client's vital signs, pupils, and orientation at frequent intervals, the nurse can provide timely and appropriate care in the intensive care unit setting.