A patient was rushed to the ER because of difficulty in urination. He was diagnosed then as a cse of benign prostate hyperthropy (BPH) and was advised by the doctor to undego transurethral resection of prostate (TURP). Based on the urgency of the surgery, the nurse classifies this condition as:

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Nursing Process Test Bank Questions

Question 1 of 9

A patient was rushed to the ER because of difficulty in urination. He was diagnosed then as a cse of benign prostate hyperthropy (BPH) and was advised by the doctor to undego transurethral resection of prostate (TURP). Based on the urgency of the surgery, the nurse classifies this condition as:

Correct Answer: A

Rationale: The correct answer is A: emergency. In this scenario, the patient is experiencing difficulty in urination due to benign prostate hyperplasia (BPH), a condition that can lead to serious complications like acute urinary retention. Transurethral resection of the prostate (TURP) is a surgical procedure that is used to relieve the obstruction caused by BPH. Given the urgency of the situation and the potential for acute complications, the surgery needs to be performed immediately to prevent further harm to the patient's health. Classifying this condition as an emergency ensures prompt intervention and prioritizes the patient's well-being. Summary: - B: C.urgent (not correct): While the surgery is time-sensitive, it does not require immediate intervention like in an emergency situation. - C: elective (not correct): Elective surgeries are planned in advance and are not typically performed in urgent situations like this one. - D: required (not correct): While the surgery is necessary for the patient's condition

Question 2 of 9

A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?

Correct Answer: A

Rationale: The correct answer is A because playing card games with friends is a low-energy activity suitable for someone with decreased energy due to chemotherapy. This option promotes social interaction and mental stimulation, addressing the deficient diversional activity. B, bowling with a team, involves physical activity and may be too strenuous for someone with decreased energy. C, taking a long trip, requires significant energy and may not be feasible. D, eating lunch in a restaurant, does not address the need for diversional activity and is not specific to the client's energy limitations.

Question 3 of 9

A home care nurse is assessing a client who is taking prazosin (Minipress). Which statement by the client would support the nursing diagnosis of noncompliance with medication therapy?

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

Question 4 of 9

In assessing clients for pernicious anemia, the nurse should be alert for which of the following risk factors?

Correct Answer: A

Rationale: The correct answer is A: Positive family history. Pernicious anemia is an autoimmune condition where the body attacks its own intrinsic factor, leading to vitamin B12 deficiency. Genetic predisposition plays a significant role in the development of pernicious anemia. Family history is a key risk factor as individuals with a family history of pernicious anemia are more likely to develop the condition. Summary of why the other choices are incorrect: B: Infectious agents or toxins do not directly cause pernicious anemia, although they can lead to other types of anemia. C: Acute or chronic blood loss can result in iron-deficiency anemia, not pernicious anemia. D: Inadequate dietary intake of vitamin B12 can lead to vitamin B12 deficiency anemia, but pernicious anemia specifically involves the body's inability to absorb B12 due to intrinsic factor deficiency, not dietary intake alone.

Question 5 of 9

When caring for Mr. Reyes, the nurse should assess for

Correct Answer: B

Rationale: The correct answer is B: Altered level of consciousness. This is crucial as it can indicate various underlying health issues affecting Mr. Reyes. Assessing for this helps in detecting potential neurological, metabolic, or cardiac issues. A: Decreased carotid pulses - While important, it is not as critical as altered level of consciousness in this scenario. C: Bleeding from oral cavity - This is important to address but does not take priority over assessing Mr. Reyes' level of consciousness. D: Absence of deep tendon-reflexes - This is more specific to neurological assessments and may not be as urgent as assessing his level of consciousness.

Question 6 of 9

A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?

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.

Question 7 of 9

As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?

Correct Answer: B

Rationale: The correct answer is B because it indicates a confrontational and potentially disrespectful attitude towards the nurse. This response does not promote a collaborative and respectful communication between the daughter and the nurse. In a healthcare setting, it is important for family members to communicate effectively and respectfully with the healthcare team to ensure the best care for the patient. A: This statement shows understanding and acceptance of the symptoms of the disease, indicating good knowledge. C: This statement shows willingness to help the patient with tasks he cannot do for himself, which is a positive and caring attitude. D: This statement shows consideration for the patient's needs by planning to turn off the TV when moving to another room, which is appropriate.

Question 8 of 9

Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client’s situation?

Correct Answer: D

Rationale: The correct answer is D: Concept map care plan. This type of care plan allows the nurse to visually represent the client's entire situation, including physical, emotional, and social aspects. By using interconnected concepts and relationships, the nurse can see the whole picture and identify potential interventions. Kardex (A) is a concise patient information summary, not comprehensive. Case management (B) focuses on coordinating services but may not capture the holistic view. Critical pathways (C) outline specific steps in care but may not address the client as a whole.

Question 9 of 9

At the present time, the best treatment for cancer is complete __________ before metastasis occurs:

Correct Answer: C

Rationale: The correct answer is C: Surgical removal. Surgical removal of the cancerous tumor is the best treatment before metastasis because it physically removes the cancer cells. Chemotherapy and radiation are used to treat cancer after it has spread, not as the primary treatment. Choice D is incorrect because not all types of cancer can be effectively treated with all three options.

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