Nursing Process Final Exam Questions

Correct Answer: C

Rationale: The correct answer is C: "It is a temporary interruption in the blood flow to the brain." This response is correct because it accurately describes a transient ischemic attack (TIA) as a temporary condition where blood flow to the brain is briefly interrupted. This explanation is clear, concise, and provides the family member with an accurate understanding of TIA. Choice A is incorrect because it deflects the question and suggests involving the doctor unnecessarily. Choice B is incorrect as it inaccurately states that TIA causes permanent brain damage, which is not true. Choice D is incorrect as it simply defines the acronym without providing any meaningful information about what TIA actually is.

Correct Answer: B

Rationale: The correct answer is B because emphysema is characterized by the destruction of the alveoli walls, leading to a loss of elasticity in the lungs. This results in air becoming trapped in the lungs, making it difficult to exhale properly. Explanation for why the other choices are incorrect: A: Inflamed bronchioles causing secretions describe bronchitis, not emphysema. C: Damage to the blood supply isn't a primary feature of emphysema; it's more about lung tissue destruction. D: Large dilated sacs of sputum in the lungs is not an accurate description of emphysema; it's more related to bronchiectasis.

Correct Answer: C

Rationale: The correct answer is C: Health promotion. The nurse wrote a diagnosis related to enhancing the patient's urinary elimination abilities through self-catheterization, which focuses on promoting the patient's health and well-being. The Readiness for enhanced urinary elimination diagnosis indicates the patient's motivation and readiness to improve their urinary elimination abilities, aligning with the concept of health promotion. This type of diagnosis acknowledges the patient's potential for growth and improvement in their health status. Incorrect choices: A: Risk - This choice would be more appropriate if the diagnosis focused on potential complications or adverse events related to the patient's urinary elimination abilities. B: Problem focused - This choice would be suitable if the diagnosis identified an existing issue or problem with the patient's urinary elimination abilities that needed to be addressed. D: Collaborative problem - This choice would be relevant if the diagnosis required collaboration between healthcare providers to manage the patient's urinary elimination abilities effectively.

Correct Answer:

Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: 1. Asking about chief concerns helps to focus the interview on the patient's needs. 2. It demonstrates active listening and empathy. 3. Allows the nurse to prioritize issues and provide appropriate care. 4. Introductions are already done, and ending the interview abruptly or mentioning medication timing is not patient-centered.

Correct Answer: C

Rationale: The hallmark of nephritic syndrome is edema due to proteinuria leading to hypoalbuminemia. Protein loss in urine causes decreased colloid osmotic pressure, leading to fluid leaking into tissues, causing edema. Osmotic diuresis (A) is unrelated to nephritic syndrome. Hypolipidemia (B) and hyperproteinemia (D) are not characteristic of nephritic syndrome.