Nursing Process 1 Test Questions

Correct Answer: B

Rationale: The correct answer is B: Isolated systolic hypertension. This is because in isolated systolic hypertension, the systolic blood pressure is elevated while the diastolic blood pressure remains normal. This condition is common in older adults and is often related to aging and stiffening of the arteries. Primary hypertension (A) typically involves both elevated systolic and diastolic pressures. Secondary hypertension (C) is caused by an underlying condition. Hypertensive emergency (D) is characterized by severe elevations in both systolic and diastolic pressures with acute target organ damage.

Correct Answer: D

Rationale: The correct answer is D: Polyps. Polyps in the colon are precancerous growths that can develop into colorectal cancer over time. Identifying polyps during a medical history interview can raise suspicion for colorectal cancer due to their potential to progress into malignancy. Duodenal ulcer (A) is not directly related to colorectal cancer. Weight gain (B) is a non-specific symptom and does not specifically indicate colorectal cancer. Hemorrhoids (C) are common and usually benign, not directly linked to colorectal cancer.

Correct Answer: C

Rationale: The correct answer is C: When the temperature rises above 102F. A temperature rise above 102F is concerning as it may indicate infection or other complications post-procedure. This higher threshold helps in early detection and timely intervention. Choices A and B set lower thresholds, potentially delaying necessary medical attention. Choice D is below the typical threshold for fever and would not typically warrant physician notification in this context.

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: B

Rationale: The correct answer is B because it follows the SMART approach: Specific (monitor heart rhythm), Measurable (continuously this shift), Achievable (feed self at all mealtimes), Relevant (shortness of breath), and Time-bound (today). Choice A lacks specificity and measurability. Choice C focuses on the nurse's action, not patient outcomes. Choice D lacks specificity and measurability, focusing on the nurse's actions rather than patient outcomes.