Nursing Process Test Bank

Nursing Process Test Bank Related

Review Nursing Process Test Bank related questions and content

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?

  • A. Self-care deficient: Bathing/hygiene
  • B. Dysfunctional grieving
  • C. Ineffective cerebral tissue perfusion
  • D. Risk for injury
Correct Answer: C

Rationale: The correct answer is C: Ineffective cerebral tissue perfusion. In the late stage of AIDS, the client is at risk for neurological complications, including AIDS-related dementia due to decreased blood flow to the brain. This nursing diagnosis takes the highest priority as it directly addresses the client's impaired brain perfusion, which can lead to serious cognitive and functional deficits. Prioritizing this diagnosis ensures timely interventions to optimize cerebral blood flow and prevent further deterioration.

Summary:
A: Self-care deficient: Bathing/hygiene - important but not the highest priority compared to addressing neurological complications.
B: Dysfunctional grieving - while emotional support is essential, it is not the priority when dealing with a life-threatening physiological issue.
D: Risk for injury - while important, it is secondary to addressing the underlying cause of the dementia in this scenario.

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A client seeks care for hopeless that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question.

  • A. “Do you smoke cigarettes, cigars or pipe?”
  • B. “Have you strained your voice recently?”
  • C. “Do you eat a lot of red meat?”
  • D. “Do you eat spicy foods?”
Correct Answer: B

Rationale: The correct answer is B: “Have you strained your voice recently?” This question is relevant to the client's symptom of hopeless, as vocal strain can contribute to this issue. Asking about voice strain helps to identify a potential cause and guides further assessment and intervention.

Choice A is not directly related to the client's primary concern and does not address the underlying cause of hopeless.

Choice C is unrelated to the client's symptom and does not provide information that is pertinent to addressing the issue at hand.

Choice D is also unrelated to the client's symptom of hopeless and does not address potential contributing factors.

When teaching a client about insulin therapy, the nurse should instruct the client to avoid which over-the- counter preparation that can interact with insulin?

  • A. Antacids
  • B. Vitamins with irons
  • C. Acetaminophen preparations
  • D. Salicylate preparations
Correct Answer: D

Rationale: The correct answer is D: Salicylate preparations. Salicylate can potentiate the effects of insulin, leading to hypoglycemia. Therefore, the nurse should instruct the client to avoid this over-the-counter preparation when on insulin therapy. Antacids (A), vitamins with iron (B), and acetaminophen preparations (C) do not typically interact with insulin in a significant way.

For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?

  • A. Administering aspirin if the temperature exceeds 102○1 F (38.8○0 C)
  • B. inspecting the skin for petechiae once every shift
  • C. providing for frequent rest periods
  • D. Placing the client in strict isolation
Correct Answer: C

Rationale: The correct answer is C: providing for frequent rest periods. This intervention is essential for a client with radiation-induced thrombocytopenia to prevent further platelet depletion and reduce the risk of bleeding episodes. Rest periods help conserve energy and minimize physical exertion, which can trigger bleeding in thrombocytopenic clients.

Rationale:
1. Administering aspirin (choice A) is contraindicated in thrombocytopenia as it can further decrease platelet count and increase the risk of bleeding.
2. Inspecting the skin for petechiae (choice B) is important but not as crucial as providing rest periods in managing thrombocytopenia.
3. Placing the client in strict isolation (choice D) is not necessary for radiation-induced thrombocytopenia unless there are other specific infectious concerns.

In summary, providing frequent rest periods is the most appropriate intervention to manage radiation-induced thrombocytopenia, promoting patient

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?

  • A. I know the hallucinations are parts of the disease
  • B. I told her she is wrong and I explained to her what is right
  • C. I help her do some tasks he cannot do for himself
  • D. Ill turn off the TV when we go to another room
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.

When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?

  • A. A normal finding
  • B. An abnormal finding
  • C. A normal finding only in the older adult
  • D. An abnormal finding only in the older adult
Correct Answer: A

Rationale: The correct answer is A: A normal finding. The Darwin tubercle is a small, painless, bony nodule at the helix of the ear and is considered a normal anatomical variation. It is present in a significant portion of the population, regardless of age. It does not indicate any pathology or abnormality. Choices B, C, and D are incorrect because the presence of a Darwin tubercle is not indicative of any abnormality, and it is not limited to older adults.

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