Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A: Weight. Monitoring daily weight is crucial in assessing fluid retention and worsening heart failure symptoms. Weight gain can indicate fluid overload, a common complication in heart failure. The other choices (B: Appetite, C: Calorie count, and D: Abdominal girth) are not as directly related to monitoring heart failure severity. Appetite and calorie count may be affected by various factors unrelated to heart failure, while abdominal girth may not provide specific information on fluid status. Monitoring weight allows for early intervention and adjustments in treatment to prevent exacerbation of heart failure symptoms.

Correct Answer: B

Rationale: The correct answer is B: An above-normal anti-deoxyribonucleic acid. In SLE, the body produces antibodies against its own DNA, leading to the presence of anti-dsDNA antibodies. Elevated levels of anti-dsDNA antibodies are specific to SLE, confirming the diagnosis. A: Increased total serum complement levels are seen in SLE due to complement activation but are not specific to SLE. C: Negative antinuclear antibody test is not consistent with SLE, as ANA positivity is common in SLE. D: Negative lupus erythematosus cell test is not specific to SLE as lupus erythematosus cells are not always present.

Correct Answer: B

Rationale: Step-by-step rationale: 1. Corticotropin-secreting pituitary adenoma leads to excess adrenocorticotropic hormone (ACTH) production. 2. High corticotropin levels would be expected due to the adenoma's overproduction. 3. The high cortisol levels occur as a result of increased ACTH stimulating cortisol release from the adrenal glands. 4. Therefore, choice B (high corticotropin and high cortisol levels) is the correct answer. Summary: - Choice A is incorrect because low cortisol levels would not be expected in a client with a corticotrophin-secreting pituitary adenoma. - Choice C is incorrect because low corticotropin levels would not align with the excessive ACTH production from the adenoma. - Choice D is incorrect as both low corticotropin and low cortisol levels would not be consistent with the pathophysiology of a corticotrophin-secreting pituitary adenoma.

Correct Answer: D

Rationale: The correct answer is D: Malnutrition. Malnutrition weakens the immune system, making individuals more susceptible to contracting tuberculosis. A well-nourished individual has a stronger immune response to fight off TB bacteria. Exposure to toxic gases (A), congenital abnormalities (B), and obstruction by tumor (C) do not directly predispose a client to TB. Malnutrition is the key factor as it impairs the immune system's ability to combat the TB bacteria effectively.

Correct Answer: A

Rationale: Step 1: Type A blood has been associated with a slightly higher risk of developing gastric cancer compared to other blood types. Step 2: The nurse mentioned a 10% increase in risk, which aligns with the increased risk associated with Type A blood. Step 3: Type AB and Type B blood do not have the same increased risk for gastric cancer as Type A blood. Step 4: Type O blood is actually associated with a lower risk of gastric cancer compared to Type A blood. Step 5: Therefore, the correct answer is A: Type A blood.