Nursing Process Questions

Correct Answer: C

Rationale: Rationale: Choice C is the correct answer because following safer-sex practices is crucial in preventing the spread of HIV/AIDS. By emphasizing this point, the nurse can educate clients on reducing the risk of transmission. Safer-sex practices include using condoms and practicing monogamy. Choice A is incorrect because avoiding recreational drugs and alcohol, while important for overall health, is not directly related to preventing the spread of HIV/AIDS. Choice B is incorrect as it is essential for individuals to inform their sexual partners about their HIV status to prevent transmission and ensure informed consent. Choice D is incorrect because while it may be required by law in some places, it is not the most crucial point for preventing the spread of HIV/AIDS within a support group setting.

Correct Answer: A

Rationale: The correct answer is A because assessing the GI tract is crucial before feeding to ensure proper digestion and absorption. Bowel sounds, last BM, and distention indicate GI function. The client's neurologic status and gag reflex are important to prevent aspiration. Option B is not a primary concern before feeding. Option C is incorrect as formula should be warmed to room temperature before feeding.

Correct Answer: A

Rationale: In the evaluation phase of the nursing process, the nurse sets priorities for patient care to determine the effectiveness of nursing interventions. This involves comparing achieved outcomes with established goals. Choices B and D are related to evaluation as they involve determining whether outcomes or standards are met and documenting results of goal achievement, respectively. However, choice C, ambulating the patient, is an intervention that would typically occur in the implementation phase, not the evaluation phase. Therefore, the correct answer is A because setting priorities for patient care is a key component of the evaluation phase.

Correct Answer: D

Rationale: The correct answer is D: anorexia. In the early stage of hepatic inflammatory disorder, anorexia is the most likely symptom/sign. This is because hepatic inflammation can lead to a decrease in appetite, resulting in anorexia. Dark urine (A) is commonly associated with liver dysfunction but typically occurs later in the disease process. Occult blood in stools (B) is more indicative of gastrointestinal bleeding rather than early hepatic inflammation. Ascites (C) is the accumulation of fluid in the abdominal cavity and is a later manifestation of liver disease. Therefore, anorexia is the most likely symptom in the early stages of hepatic inflammatory disorder.

Correct Answer: C

Rationale: The correct answer is C: Generalized seizure. This type of seizure involves both hemispheres of the brain from the onset, leading to loss of consciousness and tonic-clonic jerking. It is characterized by widespread, synchronized electrical discharges. A: Focal seizures start in one area of the brain, leading to localized symptoms without loss of consciousness. B: Jacksonian seizures are a type of focal seizure characterized by a progression of jerking movements from one body part to another. D: Partial seizures involve only one part of the brain, leading to localized symptoms or altered consciousness without loss of awareness.