Nursing Process Exam Questions

Correct Answer: B

Rationale: The correct answer is B: Focused. When a nurse inspects a postoperative incision site for infection, they are conducting a focused assessment. This type of assessment is specific to a particular issue or body system, in this case, the incision site. By focusing solely on the incision site, the nurse can thoroughly evaluate for signs of infection, such as redness, swelling, warmth, or discharge. A: Complete assessments involve a comprehensive evaluation of all body systems and are not necessary for this specific situation. C: General assessments are broad and not targeted towards a specific issue like infection at an incision site. D: Time-lapse assessments involve comparing current findings to previous assessments over a period of time, which is not relevant to immediately identifying signs of infection. In summary, the correct answer is focused because it allows for a detailed evaluation of the incision site specifically for signs of infection, unlike the other options that are either too broad or not relevant to the situation.

Correct Answer: B

Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking the beta receptors in the heart, which reduces the heart's workload and oxygen demand, making it an effective treatment for angina. By blocking beta stimulation, propranolol helps to decrease heart rate, blood pressure, and myocardial contractility. This ultimately improves oxygen supply to the heart muscle. Explanation for other choices: A: Act as a vasoconstrictor - Propranolol does not act as a vasoconstrictor; it actually can cause vasodilation in some cases. C: Act as a vasodilator - Propranolol is not primarily a vasodilator; its main action is to block beta stimulation in the heart. D: Increase the heart rate - Propranolol actually decreases heart rate by blocking beta receptors in the heart.

Correct Answer: B

Rationale: Step 1: Guillain-Barre Syndrome (GBS) is characterized by a rapid onset of weakness and tingling sensations in the legs. Step 2: Paresthesia refers to abnormal sensations like tingling or numbness, which is a common initial neurological symptom of GBS. Step 3: Absent tendon reflexes may occur in GBS due to muscle weakness but are not typically the initial symptom. Step 4: Dysrhythmias and transient hypertension are not typical symptoms of GBS and are not associated with its initial presentation. In summary, choice B is correct as paresthesia of the legs is a hallmark initial neurological symptom of Guillain-Barre Syndrome, while choices A, C, and D are incorrect as they do not align with the typical presentation of GBS.

Correct Answer: C

Rationale: The correct answer is C: Romberg�s test. Romberg�s test assesses a patient's ability to maintain balance with eyes closed, relying on proprioception from the lower limbs. A lumbar injury can affect proprioception, leading to impaired balance. Rhine�s test evaluates auditory function, not affected by a lumbar injury. Pupillary reaction assesses cranial nerve function, unrelated to a lumbar injury. The patellar reflex is a deep tendon reflex, primarily involving the spinal cord segments L2-L4, not directly affected by a lumbar injury.

Correct Answer: C

Rationale: The normal range of hemoglobin in adult blood is typically between 12-18 g/dL. This range is the most common and widely accepted range based on clinical guidelines and research studies. Hemoglobin levels outside this range may indicate anemia or other health conditions. Choice A (7-11 mg) is too low for normal hemoglobin levels in adults and indicates severe anemia. Choice B (14-20 mg) is slightly higher and could be normal for some individuals, but generally, 12-18 g/dL is the standard range. Choice D (20-26 mg) is too high and may indicate dehydration or other medical conditions.