Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C because respirations of 16 is an observable and measurable data point that can be quantified. Objective data are factual, measurable, and based on observable phenomena. In contrast, choices A, B, and D are subjective data as they rely on the patient's feelings or experiences, which are not directly measurable or observable by the nurse. Reporting a headache or feeling nauseated are subjective symptoms that are based on the patient's perception and cannot be verified without further assessment. Therefore, only choice C provides objective data that can be accurately reported by the nurse.

Correct Answer: C

Rationale: The correct answer is C because in myasthenia gravis, which is characterized by muscle weakness and fatigue, the administration of edrophonium will temporarily improve muscle strength due to increased availability of acetylcholine at the neuromuscular junction. This improvement should be noted within 30 to 60 seconds after the administration of the medication. Choice A is incorrect because joint pain is not a typical response to edrophonium in the context of myasthenia gravis. Choice B is incorrect because feelings of faintness, dizziness, hypotension, and flushing are more indicative of a cholinergic crisis, which occurs when too much edrophonium is administered. Choice D is incorrect because an increase in muscle strength post-edrophonium administration would not be expected in a client with myasthenia gravis.

Correct Answer: A

Rationale: The correct answer is A: Administer the acetaminophen. The rationale is as follows: 1. The patient has a standing order for acetaminjson for headache relief. 2. The nurse has assessed that the patient needs headache relief and has not had the medication in the past 4 hours. 3. Administering the acetaminophen aligns with the prescribed treatment plan and the patient's needs. Summary: - Option B is incorrect because obtaining a verbal order is not necessary when there is a standing order. - Option C is incorrect as nursing assistive personnel should not administer medications without direct supervision. - Option D is incorrect as pain assessment should precede medication administration to ensure appropriateness.

Correct Answer: C

Rationale: The correct answer is C because respiratory rate is an observable and measurable data point, making it objective. Objective data is factual and observable, such as vital signs. Choices A, B, and D are subjective data as they rely on the patient's perception or interpretation, which can be influenced by various factors and may not always be accurate or reliable. In this case, the nurse can directly measure and document the patient's respiratory rate, making it an objective piece of information.

Correct Answer: C

Rationale: The correct answer is C because the American Cancer Society recommends women to have a mammogram annually starting at age 45, then have the option to transition to biennial screening at age 55. This recommendation is based on evidence that regular mammograms can help detect breast cancer early, increasing chances of successful treatment. Choice A is incorrect because self-examinations are no longer recommended as a routine screening method. Choice B is incorrect as clinical breast exams are not as effective as mammograms for detecting breast cancer. Choice D is incorrect as normal receptor assays are not part of routine breast cancer screening guidelines.