Fundamentals of Nursing Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C: 2, 3, and 4. High cholesterol, cigarette smoking, and a sedentary lifestyle are modifiable risk factors for developing hypertension. High cholesterol can lead to atherosclerosis, increasing blood pressure. Smoking can constrict blood vessels, raising blood pressure. Sedentary lifestyle can lead to obesity and overall poor cardiovascular health, contributing to hypertension. Race and age are non-modifiable risk factors. Choice A is incorrect because it includes race, a non-modifiable factor. Choice B is incorrect because it includes age, which is also non-modifiable. Choice D is incorrect because it includes all factors, including non-modifiable ones.

Correct Answer: D

Rationale: The correct answer is D, suggesting the use of glasses or contact lenses. This is because as older clients experience lens changes associated with aging, they may develop presbyopia or other vision issues that can be corrected with corrective lenses. Glasses or contact lenses can help improve their vision and quality of life. A, offering teaching aids with large-sized letters, may be helpful for clients with visual impairments but may not directly address the specific lens changes associated with aging. B, suggesting reduced visual activity, is not beneficial as it may further limit the client's engagement in daily activities and social interactions. C, suggesting the use of eye drops for comfort, may provide temporary relief for dry eyes but does not address the underlying lens changes affecting vision.

Correct Answer: D

Rationale: Autoimmunity is when the immune system mistakenly attacks the body's own cells. Choice D is correct because it reflects this key feature - the inability to differentiate self from nonself. This leads to the immune system targeting healthy tissues. Choices A, B, and C are incorrect as they do not accurately describe autoimmunity. Choice A refers to endotoxins destroying B cells, which is not the definition of autoimmunity. Choice B mentions overproduction of reagin antibody, which is not related to autoimmunity. Choice C is incorrect as autoimmunity does not involve depression of the immune response but rather an inappropriate immune response.

Correct Answer: B

Rationale: The correct answer is B: All women over age 40 should have an annual mammogram. The American Cancer Society recommends annual mammograms starting at age 40 for women with an average risk of breast cancer. This is based on evidence showing that regular mammograms starting at age 40 help in early detection and improve outcomes. Choice A is incorrect because the recommended age is 40, not 30. Choice C is incorrect as it focuses only on family history, while screening guidelines are based on overall risk factors. Choice D is incorrect because feeling at risk alone is not a sufficient indication for annual mammograms without considering other risk factors.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. This involves analyzing assessment data, utilizing critical thinking skills to identify patient problems, and formulating nursing diagnoses. Diagnostic reasoning is the process of synthesizing information to make clinical judgments and determine appropriate interventions. A: Assigning clinical cues - Incorrect. This refers to identifying observable signs or symptoms, not the process of developing a nursing diagnosis. B: Defining characteristics - Incorrect. This term is often used to describe the symptoms or manifestations associated with a nursing diagnosis, not the process of deriving the diagnosis. D: Diagnostic labeling - Incorrect. This is the final step in the nursing diagnosis process where the nurse assigns a label to the identified patient problem, not the process of critical thinking and data analysis.