The nursing diagnosis Body Image Disturbance is most likely to be written

for which of the following persons?

A.) A patient with above the knee amputation
B.) A patient with second degree burns
C.) A quadriplegic patient
D.) A person entering the health care system after moving from
wellness to illness
The nurse should assess the activity tolerance of the patient with which of
the following conditions?
A.) Diabetes mellitus
B.) Diarrhea
C.) Anemia
D.) Kidney stones
Activity intolerance is an appropriate nursing diagnosis for a client with
anemia. IN anemia, there is low oxygen-carrying capacity of the blood, so
the client experiences weakness and fatigue
Which of the following statements clearly defines therapeutic
communication?
A.) Therapeutic communication is an interactional process which is
primarily directed by the nurse
B.) Therapeutic communication is conveys feelings of warmth, acceptance
and empathy from the nurse to a patient in a relaxed atmosphere
C.) Therapeutic communication is a reciprocal interaction based on
trust and aimed at identifying patient needs and developing mutual
goals
D.) Therapeutic communication is the assessment component of the
nursing process
ANS; C
Therapeutic communication is a reciprocal interaction based on trust and
aimed at identifying patient needs and developing mutual goals.
1.) Which of the following is incorrect statement of nursing diagnosis?
A.) High risk for ineffective airway clearance related to pneumonia
B.) High risk for injury related to dizziness
C.) Constipation related to decreased activity and fluids as manifested by
small, hard, formed stool every three days
D.) Anxiety related to insufficient knowledge regarding surgical experience
ANS: A
> is incorrect statement of nursing diagnosis (refer to NANDA, appendix A).
B,C and D are correct statement of nursing diagnosis.
6.) A process of heat loss which involves the transfer of heat from one
surface to another is:
A.) Radiation
B.) Conduction
C.) Convection
D.) Evaporation
ANS: B
> Conduction is the process of heat loss which involves the transfer of heat
from one surface to another
The client with fever had been observed to experience elevated
temperature for few days, followed by 1 to 2 days of normal range of
temperature. The type of fever he is experiencing is:
A.) Intermittent fever
B.) Relapsing fever
C.) Remittent fever
D.) Constant fever
ANS: B
> Relapsing fever is “on-and-off” fever
13.) The difference between the systolic pressure and the diastolic
pressure is:
A.) Apical rate
B.) Cardiac rate
C.) Pulse deficit
D.) Pulse pressure
ANS: D
> Pulse pressure is the difference between systolic pressure and diastolic
pressure.
39.) The maximum time for applying suction is:
A.) 5-10 seconds
B.) 10-15 seconds
C.) 15-20 seconds
D.) 20-30 seconds
ANS: B
> The maximum time for applying suction is 10 to 15 seconds. This is to
prevent hypoxia
71.) Which of the following is inappropriate nursing action when
administering NGT feeding?
A.) Assist the client in Fowler’s position
B.) Introduce feeding slowly
C.) Place the feeding 24 inches above the point of insertion of NGT
D.) Instill 60mls of water into the NGT after feeding
ANS: C
> During NGT feeding, the height of the feeding is 12 inches above the
point of NGT insertion, not 24 inches. If the height of feeding is too high,
this results to very rapid introduction of feeding. This may trigger nausea
and vomiting.