Nursing Process Test Questions

Correct Answer: D

Rationale: The correct answer is D because pupil size is not typically a part of a routine neurological examination. A: Eye movements are assessed to evaluate cranial nerve functions. B: Reflexes help determine the integrity of the spinal cord and peripheral nervous system. C: Nuchal rigidity is important to assess for signs of meningitis or other neurological conditions. In contrast, pupil size is more relevant in ophthalmological examinations or when assessing response to specific medications affecting the pupil size.

Correct Answer: A

Rationale: The correct answer is A: Preventing infection. With a low WBC count of 3,000/ul, the client is at high risk for infection due to compromised immune function. Priority is to prevent infection by implementing strict infection control measures, such as hand hygiene, sterile techniques, and isolation precautions. Alleviating pain (B) would be important but not the priority in this case. Controlling infection (C) is similar to preventing infection and would be a secondary intervention. Monitoring blood transfusion reactions (D) is not relevant to the client's current lab values.

Correct Answer: E

Rationale: The correct answer is not provided in the choices. However, if I were to choose from the given options, the most appropriate would be C: "Because they are prone to reduced renal efficiency." This is important because older adults may have decreased kidney function, leading to potential complications with IV therapy. Option A is incorrect as defense mechanisms are not directly related to monitoring IV therapy. Option B is incorrect as fluid overload is a general concern with IV therapy regardless of age. Option D is irrelevant to the need for monitoring IV therapy in older adults.

Correct Answer: D

Rationale: The correct answer is D. Parkinson's disease is characterized by bradykinesia, tremor, and muscle rigidity. Bradykinesia refers to slowness of movement, tremor involves involuntary shaking, and muscle rigidity causes stiffness and resistance to movement. These three symptoms are commonly known as the classic triad of Parkinson's disease. Therefore, selecting "All of the above" (D) is the correct choice as it encompasses all the key features of Parkinson's disease. Choices A, B, and C individually are incorrect because they do not fully capture the comprehensive presentation of symptoms in Parkinson's disease.

Correct Answer: B

Rationale: The correct answer is B: Offering emotional support. In the preoperative phase, a nurse's role includes comforting and reassuring the patient to reduce anxiety and promote emotional well-being. This is crucial for the patient's overall experience and can positively impact their recovery. Obtaining preoperative orders (A) is typically the responsibility of the physician. Explaining the surgical procedure (C) is usually done by the surgeon. Providing informed consent (D) involves ensuring the patient understands the risks and benefits of the procedure, which is typically the responsibility of the healthcare provider performing the procedure.