Nursing Process Final Exam Questions

Correct Answer: A

Rationale: The correct answer is A. When someone is extremely confused, providing new information slowly and in small amounts can help prevent overwhelming stress and further confusion. This approach allows the individual to process information more effectively and reduces the risk of escalating confusion or delirium as a defense mechanism. Choices B, C, and D are incorrect because destruction of brain cells, teaching progression, and giving minimal information are not directly related to managing confusion in this scenario.

Correct Answer: B

Rationale: The correct answer is B: To carry out the plan of care. In the nursing process, implementation is the phase where nurses put the established care plan into action by delivering the interventions outlined to meet the client's needs. This step is crucial as it ensures that the care plan is executed effectively and efficiently. Establishing priorities (A) is done during the planning phase, identifying client outcomes (C) is part of the evaluation phase, and validating nursing diagnoses (D) is typically done during the assessment phase, not implementation.

Correct Answer: D

Rationale: The correct answer is D because a normal corneal light reflex involves light being reflected at the same spot in both eyes. This indicates that both eyes are aligned properly and focusing light in the same direction. Choice A is incorrect because it refers to accommodation, not the corneal light reflex. Choice B is incorrect as convergence is related to eye movement, not the corneal light reflex. Choice C is incorrect as pupil constriction in response to light is known as the pupillary light reflex, not the corneal light reflex.

Correct Answer: D

Rationale: The correct answer is D, the Western blot test with ELISA. First, ELISA is used as a screening test for HIV antibodies. If positive, a confirmatory test like Western blot is needed to detect specific antibodies. Western blot is highly specific and confirms the presence of HIV antibodies. E-rosette immunofluorescence is not typically used for HIV diagnosis. Quantification of T-lymphocytes is used to monitor disease progression in HIV but does not confirm HIV infection. ELISA alone is not confirmatory; it needs to be followed by a more specific test like Western blot.

Correct Answer: A

Rationale: The correct answer is A: Adrenal cortex. Primary hyperaldosteronism is a condition where the adrenal cortex produces too much aldosterone hormone, leading to hypertension. The adrenal medulla secretes adrenaline and noradrenaline, not aldosterone, making option B incorrect. The pancreas secretes insulin and glucagon, not aldosterone, making option C incorrect. Option D is incorrect because the adrenal cortex is responsible for aldosterone secretion in primary hyperaldosteronism.