Nursing Process Test Questions

Correct Answer: B

Rationale: The correct answer is B: Use pressure relieving devices when the client is in bed. This is because pressure ulcers are a common risk for individuals with neuromuscular disorders due to immobility. Pressure relieving devices such as special mattresses or cushions help redistribute pressure and prevent skin breakdown. Incorrect choices: A: Preventing strenuous exercises is not directly related to preventing skin breakdown in this case. C: Placing the client in Fowler's position may be beneficial for respiratory issues but does not directly address skin integrity. D: Avoiding daily baths with soaps may lead to poor hygiene and does not specifically address the risk of skin breakdown.

Correct Answer: A

Rationale: The correct answer is A: Preventing infection. With a low WBC count of 3,000/ul, the client is at high risk for infection due to compromised immune function. Priority is to prevent infection by implementing strict infection control measures, such as hand hygiene, sterile techniques, and isolation precautions. Alleviating pain (B) would be important but not the priority in this case. Controlling infection (C) is similar to preventing infection and would be a secondary intervention. Monitoring blood transfusion reactions (D) is not relevant to the client's current lab values.

Correct Answer: D

Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.

Correct Answer: C

Rationale: Step-by-step rationale: 1. INH (Isoniazid) can lead to peripheral neuropathy due to vitamin B6 deficiency. 2. Pyridoxine is vitamin B6, which helps prevent neuropathy. 3. Supplementing with pyridoxine can counteract the deficiency caused by INH. 4. Thus, option C, supplementing the diet with pyridoxine, is the correct choice. Summary: - Option A is incorrect as a low cholesterol diet does not address the vitamin B6 deficiency. - Option B is incorrect as excessive bed rest does not prevent neuropathy. - Option D is incorrect as sun exposure is not related to the prevention of peripheral neuropathy.

Correct Answer: D

Rationale: The correct answer is D: The client is experiencing a mild overdosage. Tinnitus is a common symptom of aspirin toxicity. Aspirin overdose can lead to tinnitus due to its ototoxic effects. This occurrence indicates that the client may be taking too much aspirin, resulting in toxicity. The other choices (A, B, C) are incorrect because tinnitus is not a normal side effect of aspirin working correctly, upper GI bleed, or a metallic taste in the mouth.