Nursing Process Practice Questions

Correct Answer: B

Rationale: The correct answer is B because the internal mammary and internal thoracic arteries in the chest are commonly used for grafting due to their size, durability, and long-term patency. These arteries have a better track record for successful grafting procedures compared to the other options. The basic and cephalic veins in the arm (Option A) are typically used for venous procedures, not arterial grafting. The saphenous vein in the leg (Option C) is also commonly used for grafting, but the internal mammary and internal thoracic arteries are preferred for their better outcomes. The radial artery in the arm (Option D) is less commonly used for grafting compared to the internal mammary and internal thoracic arteries.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. This is the first step in the problem-oriented approach as it helps the nurse understand the immediate issues and prioritize data collection. By focusing on the presenting situation, the nurse can gather relevant information efficiently. A: Completing questions in chronological order may not address the current problem effectively. C: Making accurate interpretations of the data comes after data collection, not as the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to guide what observations are necessary.

Correct Answer: A

Rationale: Correct Answer: A - Cerebral edema Rationale: 1. SIADH leads to water retention and dilutional hyponatremia. 2. Diuretic therapy aims to increase urine output and correct fluid imbalance. 3. If the client does not comply, excessive water retention can lead to cerebral edema. 4. Cerebral edema is a serious complication that can cause neurological deficits. Summary: - B: Severe hyperkalemia is unlikely as diuretics would help excrete excess potassium. - C: Hypovolemic shock is not expected as fluid restriction may prevent rapid volume loss. - D: Tetany is not a direct consequence of non-compliance with treatment for SIADH.

Correct Answer: C

Rationale: The correct answer is C: 5 years. In ALS, 50% of patients have a life expectancy of around 3-5 years from the time of diagnosis. This is due to the progressive nature of the disease, leading to rapid deterioration of motor neurons and muscle function. Choice A (3 years) is too specific and may not apply to exactly 50% of patients. Choice B (10 years) and D (20 years) are too optimistic and do not align with the typical prognosis of ALS, where the majority of patients have a shorter life expectancy. Therefore, based on the average survival rates and disease progression, choice C is the most accurate representation of the normal life expectancy for 50% of ALS patients.

Correct Answer: C

Rationale: Correct Answer: C - ACTH Rationale: 1. ACTH (adrenocorticotropic hormone) can help control symptoms and induce remission in multiple sclerosis by reducing inflammation. 2. ACTH stimulates the production of cortisol, a natural anti-inflammatory hormone. 3. By reducing inflammation in the central nervous system, ACTH can help manage symptoms and promote remission. Summary of other choices: A: Acyclovir - Antiviral medication used to treat herpes infections, not effective for multiple sclerosis. B: Thyrotropin - Hormone that stimulates thyroid function, not used in the treatment of multiple sclerosis. D: Benadryl - Antihistamine used for allergies and itching, not indicated for multiple sclerosis management.