Nursing Process Exam Questions

Correct Answer: B

Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, such as signs and symptoms exhibited by the patient. This helps in identifying the specific health issues that the patient is currently experiencing. In contrast, a risk nursing diagnosis is focused on potential health problems that the patient may develop in the future. Possible nursing diagnosis involves uncertain or unclear health issues that require further assessment. Wellness diagnosis is aimed at enhancing health and promoting well-being, rather than addressing existing health problems. Therefore, the presence of major defining characteristics is crucial in confirming an actual nursing diagnosis.

Correct Answer: B

Rationale: The correct answer is B: heparin. Heparin is an anticoagulant used for immediate treatment of pulmonary embolism to prevent further clot formation. It acts quickly by inhibiting clotting factors. Warfarin (A) is used for long-term anticoagulation but has a slower onset. Dexamethasone (C) is a corticosteroid used for inflammation, not thrombosis. Protamine sulfate (D) is used to reverse the effects of heparin but is not indicated for initial treatment.

Correct Answer: A

Rationale: The correct answer is A: Sinusitis. Allergic rhinitis causes inflammation in the nasal passages, leading to congestion and blockage of the sinuses. If the patient does not comply with the treatment regimen, the inflammation can worsen, increasing the risk of developing sinusitis, which is an infection or inflammation of the sinuses. Sinusitis can result in severe pain, pressure, and potentially lead to complications. Summary of other choices: B: Lymphadenopathy - Enlargement of lymph nodes, not directly related to non-compliance with treatment for allergic rhinitis. C: Anaphylaxis - Life-threatening allergic reaction, not a typical consequence of non-compliance with treatment for allergic rhinitis. D: Angioedema - Swelling of deeper layers of skin, usually associated with allergies but not a common outcome of non-compliance with treatment for allergic rhinitis.

Correct Answer: B

Rationale: The correct answer is B: Positioning the patient on his or her side. This is essential for a lumbar puncture as it helps to open up the spinal spaces, making it easier and safer for the procedure. Positioning the patient on their side also helps prevent complications such as nerve damage or spinal fluid leakage. A: Administering enemas until clear is unnecessary and not directly related to preparing a patient for a lumbar puncture. C: Removing all metal jewelry is important to prevent interference with imaging studies, but it is not directly related to preparing for a lumbar puncture. D: Removing the patient�s dentures is not specifically required for a lumbar puncture procedure.

Correct Answer: B

Rationale: The correct answer is B: Amenorrhea. Danazol is a synthetic steroid used to treat fibrocystic breast disease by suppressing ovulation and hormonal fluctuations. This leads to a decrease in menstrual bleeding, resulting in amenorrhea. Nausea and confusion are not common adverse reactions of danazol. Hypotension is also not associated with danazol use. In summary, amenorrhea is the expected side effect due to the drug's mechanism of action, making it the correct choice compared to the other options.