Nursing Process Questions and Answers PDF

Correct Answer: A

Rationale: The correct answer is A because signs of brain injury, such as altered level of consciousness, unequal pupil size, and clear fluid draining from the nose or ears, indicate a need for urgent medical attention. Choice B is incorrect because hemorrhaging from the oral cavity is not a common sign of a skull fracture. Choice C is incorrect as elevating the foot of the bed is not appropriate for a skull fracture but may be done for shock. Choice D is incorrect because decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.

Correct Answer: B

Rationale: The correct answer is B: Cerebral edema. Hypernatremia is an elevated sodium level in the blood, which can lead to osmotic shifts causing water to move out of cells, including brain cells. This can result in cerebral edema, potentially leading to neurological complications. Incorrect choices: A: Red blood cell crenation - This occurs in hypertonic solutions, not hypernatremia. C: Red blood cell hydrolysis - Hypernatremia doesn't directly cause red blood cell hydrolysis. D: Renal shutdown - Hypernatremia can stress the kidneys, but it doesn't typically lead to renal shutdown.

Correct Answer: B

Rationale: The correct answer is B: Stage 2 hypertension. The patient's BP readings consistently fall within the range of 160-179 systolic or 100-109 diastolic, which aligns with the criteria for Stage 2 hypertension based on the current guidelines. This classification indicates a higher level of hypertension that requires prompt medical attention and intervention to reduce the risk of complications. Choices A, C, and D are incorrect because they do not correspond to the BP readings provided, falling outside the range for prehypertension, Stage 1 hypertension, and posthypertension.

Correct Answer: D

Rationale: The correct answer is D: Sigmoidoscopy. This procedure allows direct visualization of the lower colon and rectum, enabling the detection of colorectal cancer. Stool hematest (A) detects blood in the stool but does not confirm cancer. Abdominal CT (B) can show abnormalities but is not specific for colorectal cancer. CEA scan (C) measures a tumor marker but is not definitive for diagnosis. Sigmoidoscopy (D) is the gold standard for diagnosing colorectal cancer as it allows for direct visualization and tissue biopsy.

Correct Answer: A

Rationale: The correct answer is A: Peripheral vision. When testing visual fields, the nurse evaluates the ability to see objects outside the direct line of sight, which is indicative of peripheral vision. Peripheral vision helps detect objects and movement in the side vision. Distance vision (B) refers to the ability to see clearly at a distance, while near vision (C) pertains to close-up vision. Central vision (D) is essential for focusing on details and seeing straight ahead. Therefore, A is the correct choice as it specifically pertains to the assessment of visual fields.