Nursing Process Exam Questions

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Nursing Process Exam Questions Questions

Question 1 of 5

In the presence of coma or unconsciousness, the major therapeutic measure includes:

Correct Answer: A

Rationale: The correct answer is A: Maintenance of a clear airway. In cases of coma or unconsciousness, ensuring a clear airway is crucial to prevent respiratory complications and maintain oxygenation. This involves positioning the patient correctly, suctioning if necessary, and monitoring breathing. Choice B, good nursing care, is too broad and does not address the immediate priority of airway management. Choice C, retention of a catheter, is irrelevant to managing a coma or unconsciousness. Therefore, the correct therapeutic measure in this scenario is to focus on maintaining a clear airway to support respiratory function.

Question 2 of 5

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Correct Answer: A

Rationale: Step 1: Recognize cultural differences in communication styles. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness. Step 2: Understand that the patient's behavior may not indicate depression but rather a cultural norm. Step 3: Adjust communication approach by respecting the patient's cultural preferences. Step 4: Building trust and rapport by acknowledging and accommodating cultural differences. Summary: Choice A is correct as it acknowledges and respects cultural differences. Choices B, C, and D are incorrect as they do not consider cultural aspects and may lead to misinterpretation and inappropriate actions.

Question 3 of 5

A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?

Correct Answer: D

Rationale: The correct answer is D because a class V finding on a Pap test indicates severe dysplasia or carcinoma in situ, which requires further evaluation through a biopsy to confirm the presence of abnormal cells. This finding is not normal and necessitates immediate action for diagnosis and potential treatment. Choices A, B, and C are incorrect because they do not address the urgency and seriousness of a class V finding, which mandates prompt follow-up to rule out or confirm the presence of precancerous or cancerous cells.

Question 4 of 5

In order to educate clients, the nurse should understand that the most common site of cancer for a female is the:

Correct Answer: C

Rationale: The correct answer is C: Uterine body. The rationale is that the most common site of cancer for females is uterine body, specifically endometrial cancer. This is due to the high prevalence of hormonal imbalances and estrogen exposure, which are risk factors for this type of cancer. The other choices, A: Uterine cervix, B: Vagina, and D: Fallopian tube, are less common sites of cancer in females compared to the uterine body. Understanding the prevalence and risk factors associated with each site of cancer is crucial for nurses to educate clients effectively.

Question 5 of 5

The nurse is reviewing a patient�s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient�s kidney function lab results are abnormal, and the patient�s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

Correct Answer: A

Rationale: The correct answer is A: Diagnosis. In this scenario, the nurse needs to analyze the data and identify the patient's problem, which is urinary retention due to abnormal kidney function and decreased oral intake. This step is crucial to develop a care plan. Planning (B) comes after diagnosis, where interventions are determined. Implementation (C) involves executing the care plan, and Evaluation (D) is the final step to assess the effectiveness of interventions.

Similar Questions

The nurse is reviewing a patient�s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient�s kidney function lab results are abnormal, and the patient�s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
The nurse is caring for a patient who requires a complex dressing change. While in the patient�s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?
Which of the ff. type of eyedrops does the nurse understand is given to constrict the pupil, permitting aqueous humor to flow around the lens?
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient�s headache. Which action by the nurse is priority for this patient?

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