Nursing Process Exam Questions

Correct Answer: B

Rationale: The correct answer is B: vasoconstriction, vasospasms. 1. Raynaud's disease involves exaggerated vasoconstriction and vasospasms of blood vessels in response to cold or stress. 2. Smoking aggravates vasoconstriction and vasospasms by constricting blood vessels further. 3. This can worsen symptoms for individuals with Raynaud's disease. 4. Choices A, C, and D do not directly relate to the mechanism of Raynaud's disease and smoking.

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.

Correct Answer: A

Rationale: The correct answer is A: Muscle weakness. After unilateral adrenalectomy, there is a risk of hyperkalemia due to decreased aldosterone production. Aldosterone helps regulate potassium levels in the body. Muscle weakness is a common symptom of hyperkalemia as high potassium levels can affect muscle function. Diaphoresis, tremors, and constipation are not typically associated with hyperkalemia. Diaphoresis is excessive sweating, tremors are involuntary muscle movements, and constipation is difficulty passing stool. These symptoms are not directly related to potassium imbalance.

Correct Answer: B

Rationale: The correct answer is B: Focused. When a nurse inspects a postoperative incision site for infection, they are conducting a focused assessment. This type of assessment is specific to a particular issue or body system, in this case, the incision site. By focusing solely on the incision site, the nurse can thoroughly evaluate for signs of infection, such as redness, swelling, warmth, or discharge. A: Complete assessments involve a comprehensive evaluation of all body systems and are not necessary for this specific situation. C: General assessments are broad and not targeted towards a specific issue like infection at an incision site. D: Time-lapse assessments involve comparing current findings to previous assessments over a period of time, which is not relevant to immediately identifying signs of infection. In summary, the correct answer is focused because it allows for a detailed evaluation of the incision site specifically for signs of infection, unlike the other options that are either too broad or not relevant to the situation.

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.