Nursing Process Test Questions

Correct Answer: C

Rationale: The correct answer is C: Avoiding the use of carbonated beverages. Carbonated beverages often have high sodium content, which can contribute to increased sodium intake. By avoiding these beverages, the client can significantly reduce their sodium consumption. Explanation: 1. Carbonated beverages often contain added sodium for flavor enhancement. 2. By avoiding carbonated beverages, the client eliminates a significant source of hidden sodium in their diet. 3. This dietary practice directly targets reducing sodium intake without compromising other nutritional aspects of the diet. Summary of other choices: A: Increasing the use of dairy products - Dairy products do not necessarily impact sodium intake significantly. B: Using an artificial sweetener in coffee - Artificial sweeteners do not contribute to sodium intake. D: Using catsup for cooking and flavoring food - Catsup is high in sodium and would not help in reducing sodium intake.

Correct Answer: C

Rationale: The correct answer is C. In hypothyroidism, the thyroid gland is underactive, leading to symptoms like puffiness of the face and hands due to fluid retention. This occurs as a result of decreased metabolism. Options A and B are symptoms of hyperthyroidism, where the thyroid gland is overactive. Option D is a symptom of goiter, which is thyroid gland swelling, not specific to hypothyroidism. Therefore, the correct answer is C based on the characteristic symptoms of hypothyroidism.

Correct Answer: D

Rationale: The correct answer is D because pupil size is not typically a part of a routine neurological examination. A: Eye movements are assessed to evaluate cranial nerve functions. B: Reflexes help determine the integrity of the spinal cord and peripheral nervous system. C: Nuchal rigidity is important to assess for signs of meningitis or other neurological conditions. In contrast, pupil size is more relevant in ophthalmological examinations or when assessing response to specific medications affecting the pupil size.

Correct Answer: C

Rationale: Correct Answer: C - Autoimmune disorders include connective tissue (collagen) disorders. Rationale: Autoimmune disorders involve the immune system mistakenly attacking healthy cells and tissues in the body, which can lead to various conditions, including connective tissue disorders like rheumatoid arthritis. Providing this information to the client and family is crucial for understanding the nature of autoimmune disorders and the potential impact on the body. Summary of other choices: A: False-negative or false-positive serologic tests can occur in autoimmune disorders, so this statement is not specific enough to be the most appropriate information to provide. B: Advanced medical interventions can manage symptoms but not cure autoimmune disorders, making this statement inaccurate and misleading. D: Autoimmune disorders can present with a wide range of symptoms and can be challenging to diagnose, but this statement does not address the specific link between autoimmune disorders and connective tissue disorders.

Correct Answer: C

Rationale: The correct answer is C, Disturbed body image related to the incision scar. This is the most appropriate nursing diagnosis as the client's concern about wearing a scarf around his neck post-surgery indicates a potential disturbance in body image. This diagnosis addresses the client's emotional response to physical changes, which is common in surgical patients. Choice A is incorrect because impaired physical mobility is not directly related to the client's worry about wearing a scarf. Choice B is incorrect as ineffective denial does not directly address the client's specific concern about body image. Choice D is also incorrect as the risk of injury is not the primary issue in this scenario; it is more about the client's perception of their appearance post-surgery. In summary, the client's worry about wearing a scarf post-surgery indicates a disturbance in body image, making choice C the most appropriate nursing diagnosis.