Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A: Use aseptic technique for the insertion site. Aseptic technique is necessary to prevent infection when accessing the intracranial pressure monitoring system. Aseptic technique involves maintaining a sterile field during the insertion process, reducing the risk of introducing pathogens. Using clean technique for cleansing connections (choice B) may introduce contaminants to the insertion site. Sterile technique for cleansing the insertion site (choice C) is not necessary and may be overly stringent. Closing leaks in the tubing with tape (choice D) does not address the prevention of infection at the insertion site.

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: D

Rationale: The correct answer is D: Chronic ache or pain. Persistent cough and chronic ache or pain are both common warning signs of cancer. Chronic pain can be a symptom of various types of cancer, signaling the presence of a tumor or cancerous growth. It is important for the client to seek medical evaluation to rule out any underlying serious condition. A: Persistent nausea is not typically considered a common warning sign of cancer. While it can be a symptom in certain types of cancer or due to treatment side effects, it is not as prominent as chronic ache or pain. B: Indigestion is a common symptom that can be caused by various non-cancer-related issues such as dietary habits, stress, or gastrointestinal disorders. It is not typically considered a direct warning sign of cancer. C: Rash is generally not a common warning sign of cancer. Rashes are more commonly associated with skin conditions, allergic reactions, or infections rather than being an indicator of cancer.

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: 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.