Nursing Process Final Exam Questions

Correct Answer: C

Rationale: The correct answer is C: severe, unrelieved pain. Compartment syndrome is characterized by increased pressure within a muscle compartment leading to decreased blood flow and tissue damage. Severe, unrelieved pain is a hallmark sign as the pressure builds up. Weak movement of the patient's toes (choice A) could indicate nerve damage but is not specific to compartment syndrome. Decreased pedal pulses (choice B) could suggest vascular compromise but are not specific to compartment syndrome. Presence of foot pallor (choice D) could indicate poor circulation but is not a definitive sign of compartment syndrome.

Correct Answer: C

Rationale: The correct answer is C: Health promotion. The nurse wrote a diagnosis of Readiness for enhanced urinary elimination, which indicates the patient's willingness to improve their urinary elimination abilities. Health promotion diagnoses focus on improving the client's well-being and enhancing their health potential. In this scenario, the patient's desire to learn self-catheterization aligns with health promotion as it involves empowering the patient to take an active role in their care. Choice A (Risk) is incorrect because the patient is not currently at risk for urinary elimination issues, but rather seeking to enhance their abilities. Choice B (Problem focused) is incorrect as the diagnosis is not about addressing a current problem but rather focusing on potential improvement. Choice D (Collaborative problem) is incorrect as it does not involve collaboration between healthcare providers but rather focuses on the patient's readiness and willingness to enhance their own health outcomes.

Correct Answer: B

Rationale: The correct answer is B: Ask the patient to return to the room, so the nurse can inspect the abdomen. Rationale: 1. Patient safety: By examining the patient's abdomen, the nurse can assess for any signs of distress or potential medical issues. 2. Patient-centered care: It is essential to prioritize the patient's well-being by addressing their concerns promptly and appropriately. 3. Professional responsibility: Nurses are trained to assess and evaluate patient symptoms to provide necessary care and support. Summary: A: Requesting the family to leave does not address the patient's symptoms and may disrupt the patient's support system. C: Asking about bowel movements and offering food may not be appropriate if the patient is experiencing stomach discomfort. D: Offering food without proper assessment may worsen the patient's condition and is not recommended before a proper evaluation.

Correct Answer: A

Rationale: The correct answer is A: Have the patient lie flat for 6 to 8 hours after a lumbar puncture to prevent complications like post-lumbar puncture headache. Lying flat helps maintain CSF pressure and reduce the risk of leakage. B: Keeping the patient from eating or drinking for 4 hours is not necessary after a lumbar puncture. C: Monitoring pedal pulses q4h is irrelevant to post-lumbar puncture care. D: Keeping the head of the bed elevated 30 degrees for 24 hours is not recommended after a lumbar puncture as it may increase the risk of complications.

Correct Answer: D

Rationale: Step 1: Providing referral to support groups and resources for information is essential for HIV positive clients as it offers emotional support, education, and access to resources for managing the condition. Step 2: Support groups provide a safe space for clients to share experiences, seek advice, and reduce feelings of isolation. Step 3: Resources for information help clients stay informed about their condition, treatment options, and lifestyle modifications. Step 4: Referral to support groups and resources promotes holistic care and enhances the client's overall well-being. Summary: Choices A, B, and C are incorrect as they do not address the specific needs of HIV positive clients and may even pose risks to their health. Option D is the most appropriate intervention as it focuses on comprehensive support and empowerment for clients.