Nursing Process Practice Questions

Correct Answer: C

Rationale: The correct answer is C: Airway obstruction. Postoperatively, a nurse must assess for airway patency in a client with a nasal fracture to ensure proper breathing. Any swelling or bleeding in the nasal area can lead to airway obstruction, which is a critical concern that needs immediate intervention. Choices A, B, and D are incorrect because an allergic reaction, extreme sense of smell, and stridor are not typically associated with postoperative assessment of a nasal fracture. It is crucial to prioritize airway assessment to prevent any complications related to breathing difficulties in this situation.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. This is the first step in the problem-oriented approach as it helps the nurse understand the immediate issues and prioritize data collection. By focusing on the presenting situation, the nurse can gather relevant information efficiently. A: Completing questions in chronological order may not address the current problem effectively. C: Making accurate interpretations of the data comes after data collection, not as the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to guide what observations are necessary.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by identifying the patient's main issue or reason for seeking care. This step helps prioritize data collection and guides further assessment and intervention. By focusing on the presenting situation, the nurse can gather relevant information efficiently and address the immediate concern. Incorrect choices: A: Completing questions in chronological order may not be the most effective approach as it does not prioritize the patient's current problem. C: Making accurate interpretations of data comes after data collection and analysis, not as the first step. D: Conducting an observational overview is important, but it should come after focusing on the patient's presenting situation to gather targeted data.

Correct Answer: A

Rationale: The correct answer is A: Denial. The client's refusal to accept the diagnosis of diabetes mellitus, stating that no one in their family has had it, indicates denial as a coping mechanism. Denial is a defense mechanism where individuals refuse to acknowledge unpleasant realities. In this case, the client is rejecting the diagnosis to avoid facing the reality of having a chronic condition. The other choices (B: Anger, C: Withdrawal, D: Resolution) do not fit the client's response in this scenario. Anger involves expressing frustration or hostility, withdrawal is avoiding the situation, and resolution is accepting and dealing with the issue.

Correct Answer: C

Rationale: Rationale: 1. Abdominal injection sites have a higher blood supply, leading to faster absorption. 2. Insulin absorption is faster in areas with more blood vessels. 3. Rapid absorption at the abdomen results in quicker onset of action. 4. Other sites may have slower absorption due to less blood flow. Summary: A: Incorrect. Absorption is faster at abdominal sites due to increased blood flow. B: Incorrect. Absorption varies based on injection site blood supply. C: Correct. Abdominal injection sites have rapid insulin absorption. D: Incorrect. Insulin absorption is consistent based on blood flow at injection sites.