Nursing Process Quizlet Questions

Nursing Process Quizlet Questions Related

Review Nursing Process Quizlet Questions related questions and content

A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling make his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client’s concern?

  • A. Impaired physical mobility
  • B. Disturbed body image
  • C. Risk for infection
  • D. Risk for social isolation
Correct Answer: B

Rationale: The correct answer is B: Disturbed body image. The client's concern about the external fixation device making his leg look ugly indicates a disturbance in his perception of his own body image. This diagnosis focuses on the client's feelings and emotions related to his appearance, which can impact his self-esteem and psychological well-being.

Rationale:
1. Impaired physical mobility (A) is not the most appropriate diagnosis in this scenario as the client's concern is related to the appearance of his leg, not his ability to move.
2. Risk for infection (C) is not the best choice because the client's concern is not directly related to the risk of infection but rather to the aesthetic aspect of his leg.
3. Risk for social isolation (D) is not the most suitable diagnosis as the client's concern is more about his own perception of his appearance rather than the potential impact on his social interactions.

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Which of the ff statements justifies the administration of the prescribed anticonvulsant phenytoin to a client before the intracranial surgery?

  • A. To reduce the risk of seizures before and after surgery
  • B. To avoid intraoperative complications
  • C. To reduce cerebral edema
  • D. To prevent postoperative vomiting
Correct Answer: A

Rationale: Step 1: Phenytoin is an anticonvulsant used to prevent seizures.
Step 2: Anticonvulsants are often given before surgery to reduce the risk of seizures during and after the procedure.
Step 3: In the context of intracranial surgery, controlling seizures is crucial to prevent complications like increased intracranial pressure.
Step 4: Therefore, administering phenytoin before surgery helps in reducing the risk of seizures before and after the procedure.
Summary:
- Option B (avoid intraoperative complications) is too broad and doesn't directly relate to the use of phenytoin.
- Option C (reduce cerebral edema) is not the primary indication for phenytoin in this scenario.
- Option D (prevent postoperative vomiting) is not a common reason for administering phenytoin before intracranial surgery.

A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?

  • A. lubricate the walls of the intestinal tract
  • B. soften the fecal mass and lubricate the walls of the rectum and colon
  • C. reduce bacterial content of the fecal mass
  • D. coat the walls of the intestines to prevent irritation by the hardened fecal mass
Correct Answer: B

Rationale: The correct answer is B: soften the fecal mass and lubricate the walls of the rectum and colon. First, the oil retention enema helps soften the fecal mass, making it easier to pass. Second, the oil lubricates the walls of the rectum and colon, reducing friction and making the passage of stool smoother. This helps prepare the fecal impaction for removal during the subsequent cleansing enema. Choices A, C, and D are incorrect because they do not directly address the primary goal of softening the fecal mass and lubricating the walls of the intestines to facilitate the removal of the impaction.

Toni’s disease process involves a sacral plexus. Assessment should include:

  • A. Bladder problems
  • B. Sexual activity
  • C. Bowel management
  • D. All of the above Charles is a 76 year old retired professional golfer. He has recently been diagnosed as having Parkinson’s disease.
Correct Answer: D

Rationale: The correct answer is D because a disease process involving the sacral plexus can impact bladder function (choice A), sexual activity (choice B), and bowel management (choice C). The sacral plexus is responsible for innervating pelvic organs and lower limb muscles, so dysfunction in this area can lead to issues in these functions. Bladder problems can manifest as urinary retention or incontinence, sexual activity may be affected due to changes in sensation or muscle control, and bowel management can be disrupted leading to constipation or incontinence. Therefore, assessing all these areas is crucial to understand the full impact of the disease process on the individual's quality of life.

A patient has chronic respiratory acidosis related to long-standing lung disease. Which of the following problems is the cause?

  • A. Hyperventilation
  • B. Loss of acid by kidneys
  • C. Hypoventilation
  • D. Loss of base by kidneys CARING FOR CLIENTS REQUIRING INTRAVENOUS THERAPY
Correct Answer: C

Rationale: The correct answer is C: Hypoventilation. In chronic respiratory acidosis, the lungs cannot effectively eliminate carbon dioxide, leading to an accumulation of CO2 in the blood, causing acidosis. Hypoventilation results in decreased removal of CO2, exacerbating the acidosis.

A: Hyperventilation would lead to respiratory alkalosis, not acidosis.
B: Loss of acid by kidneys would result in metabolic alkalosis, not respiratory acidosis.
D: Loss of base by kidneys would lead to metabolic acidosis, not respiratory acidosis.

In summary, the main issue in chronic respiratory acidosis is inadequate elimination of CO2 due to hypoventilation, leading to acidosis.

The nurse is preparing to administer a unit of blood to a client’s who’s anemic. After its removal from the refrigerator, the blood should be administered within:

  • A. 1 hour
  • B. 4 hours
  • C. 2 hours
  • D. 6 hours
Correct Answer: C

Rationale: The correct answer is C: 2 hours. Blood should be administered within 30 minutes to 4 hours after removal from the refrigerator to prevent bacterial growth and maintain its efficacy. Option C falls within this timeframe, ensuring safety and effectiveness. Option A (1 hour) is too short, while option B (4 hours) and option D (6 hours) exceed the recommended timeframe, increasing the risk of bacterial contamination and compromising the quality of the blood product.

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