The next steps: Differential diagnosis and initial management
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Course
Nursing
Institution
Nursing
1. Which of the following is the first step in the nursing process?
A. Diagnosis
B. Assessment
C. Planning
D. Implementation
Answer: B. Assessment
Rationale: The nursing process begins with assessment, which involves collecting, analyzing, and validating data.
_______________________________...
1. Which of the following is the first step in the nursing process?
A. Diagnosis
B. Assessment
C. Planning
D. Implementation
Answer: B. Assessment
Rationale: The nursing process begins with assessment, which involves collecting, analyzing,
and validating data.
2. When assessing a patient with chest pain, the nurse should prioritize which of the
following actions?
A. Obtain a history of the present illness
B. Perform a physical examination
C. Administer pain medication
D. Monitor vital signs
Answer: D. Monitor vital signs
Rationale: Vital signs provide immediate information about the patient’s stability and potential
deterioration.
3. The nurse is evaluating a patient with potential heart failure. Which of the following
findings would be most indicative of this condition?
A. Bradycardia
B. Orthopnea
C. Hyperventilation
D. Cyanosis
Answer: B. Orthopnea
Rationale: Orthopnea, or difficulty breathing while lying flat, is a common symptom of heart
failure.
4. A patient presents with sudden onset of severe abdominal pain. What is the nurse's
priority intervention?
A. Administer analgesics
B. Perform a physical examination
,C. Assess the patient's vital signs
D. Obtain a detailed health history
Answer: C. Assess the patient's vital signs
Rationale: Assessing vital signs is crucial to determine the stability of the patient and guide
further interventions.
5. Which of the following assessments should the nurse prioritize in a patient suspected of
having a stroke?
A. Pupillary reaction
B. Skin turgor
C. Lung sounds
D. Heart rhythm
Answer: A. Pupillary reaction
Rationale: Changes in pupillary reaction can indicate neurological deficits, which are critical in
stroke assessment.
6. What is the most appropriate initial management for a patient experiencing
anaphylaxis?
A. Administer antihistamines
B. Apply a tourniquet
C. Administer epinephrine
D. Place the patient in Trendelenburg position
Answer: C. Administer epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis and works quickly to reverse
the symptoms.
7. The nurse is preparing to discharge a patient diagnosed with diabetes mellitus. Which
statement indicates the need for further teaching?
A. "I will check my blood glucose levels daily."
B. "I can eat whatever I want as long as I take my insulin."
C. "I need to monitor my feet for any injuries."
D. "I should follow a meal plan that balances carbohydrates and proteins."
, Answer: B. "I can eat whatever I want as long as I take my insulin."
Rationale: Patients with diabetes must manage their diet carefully, not just rely on insulin to
control blood glucose levels.
8. In assessing a patient with pneumonia, which finding would the nurse expect to note?
A. Hyperactive bowel sounds
B. Dullness on percussion
C. Clear lung sounds
D. Wheezing
Answer: B. Dullness on percussion
Rationale: Dullness on percussion is indicative of fluid in the lungs, commonly seen in
pneumonia.
9. When developing a nursing care plan for a patient with chronic obstructive pulmonary
disease (COPD), which nursing diagnosis should be prioritized?
A. Impaired gas exchange
B. Ineffective airway clearance
C. Activity intolerance
D. Anxiety
Answer: A. Impaired gas exchange
Rationale: Impaired gas exchange is a primary concern in COPD and affects overall
oxygenation.
10. A nurse is assessing a patient with suspected appendicitis. Which assessment finding is
most consistent with this diagnosis?
A. Right upper quadrant pain
B. Left lower quadrant pain
C. Rebound tenderness in the right lower quadrant
D. Epigastric pain
Answer: C. Rebound tenderness in the right lower quadrant
Rationale: Rebound tenderness in the right lower quadrant is a classic sign of appendicitis.
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