Nursing Process Test Bank

Correct Answer: C

Rationale: The correct answer is C: Dopamine. Parkinson's disease is primarily caused by a deficiency of dopamine in the brain, leading to the characteristic symptoms of bradykinesia, rigidity, and tremors. Dopamine is a neurotransmitter involved in movement control. Acetylcholine (Choice A) is not directly related to Parkinson's disease, although its imbalance can contribute to other movement disorders. Serotonin (Choice B) and Phenylalanine (Choice D) are not primarily involved in the pathophysiology of Parkinson's disease.

Correct Answer: B

Rationale: The correct answer is B because it directly reflects the client's progress in physical activity, a key indicator of recovery post-myocardial infarction. Walking 500 meters without chest pain shows improved cardiovascular function and exercise tolerance. Vital signs and lab results from admission (A) are important for initial assessment but not for ongoing evaluation. Physician notes (C) may provide insights but do not directly measure the client's progress. Medications prescribed (D) are important but do not reflect the client's specific improvement in physical activity.

Correct Answer: B

Rationale: The correct answer is B because conducting the interview in a quiet environment, like the waiting area with the television turned off, reduces background noise and distractions for the patient with a hearing deficit. This allows for better communication and understanding. A: Conducting the interview in the patient's room with the door closed may still have distractions or noise from outside the room. C: Conducting the interview in the patient's room before administration of pain medication does not address the issue of reducing background noise for better communication. D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional distractions and noise, making it harder for the patient with a hearing deficit to communicate effectively.

Correct Answer: B

Rationale: The correct answer is B: Volume overload with hemodilution. In deep partial-thickness burns, there can be fluid shifts leading to volume overload. This excess fluid in the intravascular space can dilute the blood, resulting in a decreased hematocrit (Hct). Reduced Hct indicates lower concentration of red blood cells in the blood. Other choices are incorrect because hypoalbuminemia would lead to hemoconcentration, metabolic acidosis would not directly cause a reduced Hct, and lack of erythropoietin factor would primarily affect erythropoiesis but not directly lead to decreased Hct.

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, which are signs and symptoms that support the diagnosis. This helps to differentiate it from other types of diagnoses such as risk, possible, or wellness diagnoses. Risk nursing diagnoses predict potential problems, possible nursing diagnoses lack sufficient data for validation, and wellness diagnoses focus on promoting health rather than addressing current health issues. Therefore, only the actual nursing diagnosis is confirmed by the presence of observable defining characteristics.