Nursing Process Final Exam Questions

Correct Answer: C

Rationale: The correct answer is C: deposits of adipose tissue in the trunk and dorsocervical area. In Cushing's syndrome, there is excess cortisol production leading to central obesity with fat accumulation in the trunk and dorsocervical area (buffalo hump). This is due to cortisol's role in redistributing fat. A: hypotension is incorrect because individuals with Cushing's syndrome typically have hypertension due to the effects of excess cortisol on blood pressure regulation. B: thick, coarse skin is incorrect as individuals with Cushing's syndrome may have thin, fragile skin due to decreased collagen formation. D: weight gain in arms and legs is incorrect as the weight gain in Cushing's syndrome tends to be centralized in the trunk and face rather than the extremities.

Correct Answer: B

Rationale: The correct answer is B: Ambulate with assistance. Ambulating helps prevent further bone loss and strengthens muscles, important for osteoporosis patients. Bedrest can worsen bone density loss. Encouraging fluids and providing a high-protein diet are important for overall health but do not directly address the weakness associated with osteoporosis.

Correct Answer: D

Rationale: The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions." Rationale: 1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being. 2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery. 3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient. 4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes. Summary: A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs. B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses. C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.

Correct Answer: C

Rationale: The correct answer is C: Health promotion. This type of diagnosis focuses on improving the client's well-being and maximizing their health potential. By adding Readiness for enhanced urinary elimination to the care plan, the nurse acknowledges the patient's willingness to learn self-catheterization, which aligns with health promotion. Other choices are incorrect because: A (Risk) implies potential harm, B (Problem focused) focuses on current issues, and D (Collaborative problem) involves multiple healthcare providers working together on a specific problem.

Correct Answer: C

Rationale: The nurse would identify platelets at 115,000/ul as an abnormal finding because it is below the normal range of 150,000-450,000/ul. Low platelet count can lead to increased bleeding risk. RBC count and hematocrit levels are within normal ranges, making them normal findings. Option D is incorrect as platelets are abnormal.