Nursing Process Test Bank

Correct Answer: A

Rationale: The correct answer is A because playing card games with friends is a low-energy activity suitable for someone with decreased energy due to chemotherapy. This option promotes social interaction and mental stimulation, addressing the deficient diversional activity. B, bowling with a team, involves physical activity and may be too strenuous for someone with decreased energy. C, taking a long trip, requires significant energy and may not be feasible. D, eating lunch in a restaurant, does not address the need for diversional activity and is not specific to the client's energy limitations.

Correct Answer: C

Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice D) is not as reliable as urinary output for assessing fluid status.

Correct Answer: C

Rationale: The correct answer is C: Maintains skin integrity. During inguinal hernia repair surgery, maintaining skin integrity is crucial to prevent infection and ensure proper wound healing. This outcome focuses on the physical aspect of the surgery and reflects the patient's skin condition postoperatively. Verbalizing fears (A) addresses emotional concerns, demonstrating leg exercises (B) is related to postoperative rehabilitation, and explaining deep breathing exercises (D) targets respiratory function, none of which directly assess the intraoperative outcome of skin integrity.

Correct Answer: D

Rationale: The correct answer is D: To wash hands frequently. This is important in rhinitis prevention as it helps reduce the spread of viruses and bacteria that can trigger or exacerbate symptoms. Washing hands removes potential allergens and irritants, reducing the risk of rhinitis flare-ups. Choice A is incorrect as blowing the nose is necessary to clear mucus and alleviate symptoms. Choice B is irrelevant to rhinitis prevention. Choice C is not directly related to preventing rhinitis.

Correct Answer: D

Rationale: The correct answer is D: Pain related to sickle cell crisis. In a sickle cell crisis, the client experiences severe pain due to the sickling of red blood cells, which causes blockages in blood vessels. This pain is the hallmark symptom of sickle cell crisis and is a priority nursing diagnosis. The other choices are incorrect because they do not directly relate to the primary issue of sickle cell crisis. Imbalanced nutrition is not typically a priority during a crisis, disturbed sleep pattern is not a common symptom, and impaired skin integrity is not a prominent concern in sickle cell crisis.