Nursing Process Test Bank

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.

Correct Answer: C

Rationale: The correct answer is C: Vitamin D. In hypoparathyroidism, there is a deficiency of parathyroid hormone leading to low calcium levels. Vitamin D helps in the absorption of calcium from the intestines, thus aiding in maintaining normal calcium levels. It is often prescribed along with calcium supplements to support bone health and prevent complications. Folic acid (A) is not directly related to the treatment of hypoparathyroidism. Potassium (B) is not typically prescribed for this condition and can be harmful in high levels. Iron (D) is not directly involved in calcium metabolism and is not part of the standard treatment regimen for hypoparathyroidism.

Correct Answer: D

Rationale: The correct answer is D because a regular diet with extra fruits and green vegetables can provide essential nutrients for overall health, potassium-sparing diuretics can help manage potassium levels in the body, and discontinuing oral magnesium salts can prevent further complications in the patient. Option A focuses on promoting a healthy diet, B addresses specific medication for potassium management, and C avoids potential interactions with magnesium salts. Therefore, all of the measures (A, B, and C) are necessary for comprehensive management of the patient's condition.

Correct Answer: C

Rationale: The correct answer is C because asking the client if they are experiencing pain is a direct action of assessment. This step involves gathering information directly from the client to understand their condition and needs. By asking the client about pain, the nurse is actively assessing the client's well-being. A: The nurse bathing the client is not an action of assessment but rather a task related to providing care. B: The nurse documenting the incident is important for recording the event but does not directly involve assessing the client's condition. D: The nurse removing the wash basin is a task related to the physical care process and does not involve direct assessment of the client's well-being.

Correct Answer: C

Rationale: The correct answer is C: A 6-hour glucose tolerance test. This test involves measuring blood glucose levels at specific intervals after consuming a glucose solution, providing a comprehensive assessment of glucose utilization over time. This test is particularly useful in evaluating how the body processes glucose after a meal and can help diagnose conditions such as diabetes. A: A fasting blood glucose test would not provide a comprehensive picture of glucose utilization over time since it only measures glucose levels in a fasted state. B: A test of serum glycosylated hemoglobin (HbA1c) reflects average blood glucose levels over the past 2-3 months but does not directly assess glucose utilization after a meal. D: A test for urine ketones is used to detect ketones in the urine, which can indicate diabetic ketoacidosis but does not directly measure glucose utilization.