Nursing Process Exam Questions

Correct Answer: B

Rationale: The correct answer is B: Amenorrhea. Danazol is a synthetic steroid used to treat fibrocystic breast disease by suppressing ovulation and hormonal fluctuations. This leads to a decrease in menstrual bleeding, resulting in amenorrhea. Nausea and confusion are not common adverse reactions of danazol. Hypotension is also not associated with danazol use. In summary, amenorrhea is the expected side effect due to the drug's mechanism of action, making it the correct choice compared to the other options.

Correct Answer: A

Rationale: The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning findings such as abnormal kidney function, lack of voiding, and decreased oral intake, the nurse needs to move to the diagnosis step of the nursing process. This involves analyzing the data collected to identify the patient's health problems and risks. In this case, the nurse needs to determine potential underlying issues related to the kidney function abnormalities and lack of voiding, and formulate a nursing diagnosis based on the findings. Summary of other choices: B: Planning comes after diagnosis and involves setting goals and creating a plan of care. C: Implementation follows planning and involves carrying out the plan of care. D: Evaluation is the final step of the nursing process where the nurse assesses the effectiveness of the interventions implemented.

Correct Answer: C

Rationale: The correct answer is C: Drop in blood pressure and rise in heart rate. After a splenectomy, the client is at risk for orthostatic hypotension due to decreased blood volume. A drop in blood pressure and a compensatory rise in heart rate are common orthostatic changes. This occurs because the body tries to maintain perfusion to vital organs. A rise in blood pressure and heart rate (Choice A) would not align with orthostatic changes. A rise in blood pressure and drop in heart rate (Choice B) is contradictory to the body's compensatory response to maintain perfusion. Therefore, the most supportive vital sign values for abnormal orthostatic changes in this client would be a drop in blood pressure and a rise in heart rate.

Correct Answer: B

Rationale: The correct answer is B because the client remains radioactive for a period of time after the implant removal, typically around 10 days. During this time, the nurse should take precautions to limit exposure to radiation. Choice A is incorrect because bodily fluids are not highly radioactive, and proper disposal procedures should be followed. Choice C is incorrect as soiled linens should be handled appropriately to prevent contamination. Choice D is incorrect as bed rest may not be necessary, and mobility should be encouraged within safety guidelines.

Correct Answer: D

Rationale: The correct answer is D: Hypomagnesemia. Dehydration can lead to electrolyte imbalances, and hypomagnesemia can cause confusion in elderly patients. Magnesium plays a crucial role in brain function and its deficiency can result in cognitive impairment. Hyponatremia (A) typically presents with symptoms like weakness and confusion but not necessarily dehydration. Hypercalcemia (B) and hyperkalemia (C) are less likely to cause confusion in this scenario. Therefore, hypomagnesemia is the most likely electrolyte imbalance involved in the elderly nursing home resident's confusion.