Fundamentals of Nursing Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A because tachycardia (increased heart rate) and dilated pupils are classic responses of the sympathetic nervous system activation. Sympathetic nervous system is responsible for the fight or flight response, leading to increased heart rate and dilated pupils to prepare the body for quick action. Choice B is incorrect because hypoglycemia and headache are not specific to sympathetic nervous system function. Choice C is incorrect because increased peristalsis and abdominal cramping are more indicative of parasympathetic nervous system activity. Choice D is incorrect because pupil constriction and bronchoconstriction are actions of the parasympathetic nervous system, responsible for rest and digest functions.

Correct Answer: B

Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease. Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI). Step 3: Age is a risk factor for CAD but not directly linked to MI development. Step 4: Medication usage may impact risk factors but is not a direct cause of MI. Step 5: Gender can influence risk but is not the primary factor in MI development.

Correct Answer: C

Rationale: The correct answer is C: 15 to 20 g of a fast-acting carbohydrate such as orange juice. In this scenario, the client is experiencing hypoglycemia, which can lead to confusion and abnormal behavior. Administering fast-acting carbohydrates like orange juice will help quickly raise the blood sugar levels. This is the first-line treatment for conscious patients with hypoglycemia. Choice A (I.M. or subcutaneous glucagon) is used for unconscious patients or when oral intake is not possible. Choice B (I.V. bolus of dextrose 50%) is too aggressive for a conscious patient and may lead to complications. Choice D (10 U of fast-acting insulin) would further lower the blood sugar levels and worsen the situation. Administering fast-acting carbohydrates is the safest and most effective approach for conscious patients with hypoglycemia to quickly raise their blood sugar levels and resolve their symptoms.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather objective data directly from the patient's body, such as vital signs, skin condition, and overall health status. It provides a comprehensive overview of the patient's current health status and helps in establishing a baseline for further assessments and interventions. Reviewing literature (A) is important for evidence-based practice but does not directly establish a patient's database. Checking orders for tests (B) is essential but does not provide a holistic view of the patient. Ordering medications (D) is a treatment intervention and not a data collection method.

Correct Answer: B

Rationale: Step 1: Crowded living conditions do not directly increase the risk of lung cancer. Step 2: Passive smoke (choice A) and air pollution (choice C) contain carcinogens linked to lung cancer. Step 3: Diet low in fruits and vegetables (choice D) may lead to poor immune function, potentially impacting cancer risk. Step 4: In summary, crowded living conditions do not contribute to lung cancer risk compared to the other choices.