ADPIE Nursing Process Questions

ADPIE Nursing Process Questions Related

Review ADPIE Nursing Process Questions related questions and content

Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?

  • A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
  • B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
  • C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
  • D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B

Rationale: The correct answer is B. Placing the patient on the right side with support to the back, pillows for body alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled is most appropriate for a patient with right-sided paralysis following a stroke. This position helps prevent contractures by maintaining proper alignment and positioning of the limbs. Placing the washcloth to curl the fingers helps prevent hand contractures. Supporting the back and keeping the hips slightly flexed also helps prevent pressure ulcers and maintains proper body alignment.

Choice A is incorrect because tightly holding a rolled washcloth may cause discomfort and restrict blood flow.

Choice C is incorrect because placing the patient on the back with a pillow under the knees does not address the specific needs of a patient with right-sided paralysis.

Choice D is incorrect because lying on the back with trochanter rolls and a footboard does not address the specific needs of a patient with right-sided paralysis and may not prevent contractures effectively.

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A nurse conducts an assessment and notes that the client has abnormal breath sounds, a productive cough, and cyanotic lips. How should the nurse categorize these findings?

  • A. Subjective data
  • B. Objective data
  • C. Secondary data
  • D. Primary data
Correct Answer: B

Rationale: The correct answer is B: Objective data. Abnormal breath sounds, a productive cough, and cyanotic lips are all observable and measurable findings that can be verified by the nurse through assessment. Objective data refers to information that can be observed or measured, providing concrete evidence of the client's condition. In this case, the nurse directly perceives these physical signs during the assessment, making them objective data.

Summary:
- A: Subjective data involves the client's feelings or opinions, which are not directly observable by the nurse.
- C: Secondary data are information obtained from other sources, not directly from the client.
- D: Primary data are firsthand information collected directly from the client, but in this scenario, the findings are observable physical signs, making them objective data.

A 61-year old female patient with diabetes is in the emergency department after stepping on a sharp onject while walking barefoot on the beach. The patient did not notice that the object pierced the skin unitl later that evening. What problem does she probably have?

  • A. neuropathy on her peripheral
  • B. nephropathy
  • C. carpal tunnel syndrome
  • D. macroangiopathy
Correct Answer: A

Rationale: The correct answer is A: neuropathy on her peripheral. In diabetes, peripheral neuropathy is common, causing loss of sensation in the feet, making it difficult to feel injuries like stepping on a sharp object. This can lead to delayed detection of wounds, increasing the risk of infections and complications. Nephropathy (B) refers to kidney damage, carpal tunnel syndrome (C) involves compression of the median nerve in the wrist, and macroangiopathy (D) refers to large blood vessel disease, which are not directly related to the scenario described.

Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error?

  • A. Hyperventilating James with 100% oxygen before and after suctioning
  • B. Instilling 3 to 5 ml normal saline to loosen up secretion
  • C. Applying suction during catheter withdrawal
  • D. Suction the client every hour
Correct Answer: A

Rationale: The correct answer is A because hyperventilating James with 100% oxygen before and after suctioning can lead to oxygen toxicity. The rationale is as follows:
1. Hyperventilation with 100% oxygen can lead to increased oxygen levels in the blood, potentially causing oxygen toxicity.
2. Oxygen toxicity can result in lung damage and other complications.
3. It is not recommended to administer 100% oxygen continuously, especially in high concentrations.
Therefore, Wilma committing an error by hyperventilating James with 100% oxygen. Other choices are incorrect because B is a common practice to help loosen secretions, C is correct suctioning technique, and D is a reasonable frequency for suctioning depending on the client's condition.

Clients with myastherda gravis, Guillain - Barre Syndrome or amyothrophic sclerosis experience:

  • A. Progressive deterioration until death
  • B. Deficiencies of essential neurotransmitter
  • C. Increased risk of respiratory complications
  • D. Involuntary twitching of small muscle group
Correct Answer: C

Rationale: The correct answer is C: Increased risk of respiratory complications. Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis may experience respiratory muscle weakness, leading to difficulty breathing and an increased risk of respiratory complications such as pneumonia or respiratory failure. This is due to the involvement of the muscles responsible for breathing in these conditions. Progressive deterioration until death (A) is not always the case and varies depending on the condition and individual. Deficiencies of essential neurotransmitters (B) is not a common symptom in these conditions. Involuntary twitching of small muscle groups (D) is not a characteristic symptom of these neurological disorders.

What are the nursing interventions for a client with thalassemia?

  • A. Maintain the client on bed rest and protect him or her from infections
  • B. Ambulate the client frequently
  • C. Advise drinking 3 quarts (L) of fluid per day
  • D. Instruct the client to elevate the lower extremities as much as possible
Correct Answer: A

Rationale: The correct answer is A because thalassemia is a genetic blood disorder that can cause anemia and fatigue. By maintaining the client on bed rest and protecting them from infections, we can help prevent complications such as fatigue and infections due to reduced red blood cell production. Ambulating the client frequently (choice B) may lead to increased fatigue and risk of injury. Advising to drink 3 quarts of fluid per day (choice C) is not specific to thalassemia treatment and could potentially worsen symptoms. Instructing the client to elevate lower extremities (choice D) is not directly related to managing thalassemia and may not provide significant benefits in this context.

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