Nursing Process Test Bank

Correct Answer: D

Rationale: The correct answer is D: Deficient knowledge. This nursing diagnosis is appropriate because educating the patient about hypertension, its management, lifestyle modifications, and medication adherence is crucial in improving outcomes. Activity intolerance (A) and impaired physical mobility (B) are not typically primary focuses for hypertension but may be secondary concerns. Ineffective airway clearance (C) is unrelated to hypertension. Therefore, D is the most relevant option for addressing the patient's needs.

Correct Answer: C

Rationale: Step 1: Identify the correct answer - C: �I feel dizzy, I�ll skip my dose for a few days.� Step 2: Explanation - This statement indicates that the client is experiencing a known side effect of prazosin (dizziness) and plans to stop the medication temporarily without consulting the healthcare provider, showing noncompliance. Step 3: Supporting details - Skipping doses can lead to ineffective treatment and potential health risks. Step 4: Comparison with other choices: A: This statement shows the client questioning the need for medication but does not indicate current noncompliance. B: This statement demonstrates difficulty reading labels but does not directly relate to medication compliance. D: This statement shows awareness about medication interactions but does not indicate noncompliance with the prescribed medication regimen. Summary: Choice C is correct as it directly reflects noncompliance by planning to skip doses without consulting the healthcare provider, leading to potential adverse outcomes. Choices A, B, and D do not demonstrate the

Correct Answer: C

Rationale: The correct answer is C: A 6-hour glucose tolerance test. This test involves measuring blood glucose levels at specific intervals after consuming a glucose solution, providing a comprehensive assessment of glucose utilization over time. This test is particularly useful in evaluating how the body processes glucose after a meal and can help diagnose conditions such as diabetes. A: A fasting blood glucose test would not provide a comprehensive picture of glucose utilization over time since it only measures glucose levels in a fasted state. B: A test of serum glycosylated hemoglobin (HbA1c) reflects average blood glucose levels over the past 2-3 months but does not directly assess glucose utilization after a meal. D: A test for urine ketones is used to detect ketones in the urine, which can indicate diabetic ketoacidosis but does not directly measure glucose utilization.

Correct Answer: B

Rationale: The correct answer is B: Dyspnea on exertion. In older clients, dyspnea on exertion is often the earliest symptom of heart failure due to decreased cardiac reserve. This occurs when the heart cannot pump enough blood to meet the body's demands during physical activity. Increased urine output (A) is not typically an early symptom of heart failure. Swollen joints (C) are more indicative of arthritis or inflammation, not necessarily heart failure. Nausea and vomiting (D) are not typical early symptoms of heart failure and are more commonly associated with gastrointestinal issues.

Correct Answer: C

Rationale: The correct answer is C because it shows a positive self-perception and self-acceptance. By choosing the dress based on how it complements her eyes, the patient demonstrates a focus on her own preferences and self-image rather than external validation or criticism. This indicates progress towards accepting her body image. A: Choice A indicates concern about others' opinions, which shows a lack of self-assurance and reliance on external validation. B: Choice B reflects negative body image and self-criticism, indicating a lack of acceptance. D: Choice D is focused on a future event, suggesting avoidance or delay in addressing the current body image issues.