The nursing process is a sequential method of problem solving that nurses use and includes which steps?

Correct Answer: D

Rationale: The correct answer is D because it accurately reflects the sequential steps of the nursing process. Assessment is the first step to gather data, followed by diagnosis to analyze and identify the problem. Outcome identification sets goals, planning creates a care plan, implementation executes the plan, and evaluation assesses the effectiveness. Choice A is incorrect because it includes treatment before the diagnosis step, and lacks outcome identification and implementation steps. Choice B is incorrect because it includes admission and discharge planning before the assessment and planning steps. Choice C is incorrect because it includes admission and diagnosis before the assessment step, and lacks outcome identification.

Correct Answer: A

Rationale: The correct answer is A: Increased cup-to-disc ratio. On funduscopic examination of a patient with glaucoma, one would typically observe an increased cup-to-disc ratio, indicating optic nerve damage. This is a key feature of glaucoma diagnosis as it signifies progressive loss of retinal ganglion cells. AV nicking, cotton wool spots, and microaneurysms are not specific findings in glaucoma, but rather associated with other conditions such as hypertensive retinopathy and diabetic retinopathy. Therefore, they are not indicative of glaucoma on funduscopic examination.

Correct Answer: C

Rationale: The correct sequence for examining the abdomen is inspection, auscultation, percussion, and palpation. Inspection assesses overall appearance, distension, scars, and masses. Auscultation listens for bowel sounds and vascular bruits. Percussion helps identify organ borders and assess for fluid or air accumulation. Palpation evaluates tenderness, masses, and organ size. This order ensures a systematic and thorough assessment. Choice A is incorrect because palpation should occur after percussion. Choice B is incorrect as auscultation should come before percussion. Choice D is incorrect because inspection should precede auscultation.

Correct Answer: A

Rationale: The correct answer is A because percussing once over each area is not an appropriate technique. Percussion involves tapping the body surface repeatedly to produce sound waves. By percussing only once, the nurse may not accurately assess the underlying structures. Choices B, C, and D are incorrect because lifting the striking finger quickly, striking with the fingertip, and using the wrist are all appropriate percussion techniques that allow for proper assessment of underlying structures.

Correct Answer: B

Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This action should be taken next because it can provide valuable information about the underlying cause of the patient's respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the lungs or pleural space, which could be contributing to the breathing difficulties. It is an important assessment technique to determine if there are changes in lung density or presence of abnormal sounds. Counting respirations (A) is important but may not provide immediate information on the cause of distress. Waiting for a chest x-ray (C) can delay necessary interventions. Inspecting the thorax for masses or bleeding (D) is not as crucial as assessing for changes in percussion tones in a patient experiencing sudden respiratory distress.