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: D

Rationale: The correct answer is D (Lamb and peaches) because lamb is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Peaches are high in vitamin C, which enhances iron absorption. Shrimp and tomatoes (A) have some iron but are not as rich in iron as lamb. Cheese and bananas (B) are not significant sources of iron. Lobster and squash (C) also do not provide as much iron as lamb. Overall, the combination of heme iron from lamb and vitamin C from peaches makes them the most suitable choices for an anemic client requiring iron therapy.

Correct Answer: C

Rationale: The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage. A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin. B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers. D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.

Correct Answer: A

Rationale: The correct answer is A: Surgery. Surgery is the primary treatment for vaginal cancer, especially for early-stage cases. It involves removing the cancerous tissue from the vagina. Radiation (B) and chemotherapy (C) may also be used in addition to surgery in some cases, but they are not the primary treatment. Immunotherapy (D) is not a standard treatment for vaginal cancer. It is important to prioritize surgery as it directly targets and removes the cancerous cells from the affected area, increasing the chances of successful treatment and recovery.

Correct Answer: B

Rationale: The correct answer is B. To examine stiffness and rigidity of the neck, the nurse should move the client's head and chin toward the chest. This maneuver assesses for resistance and limitation in neck flexion, which can indicate stiffness and rigidity commonly seen in neurologic disorders like meningitis or cervical dystonia. A: Positioning the client flat on the bed for hours does not specifically target neck stiffness and rigidity. C: Asking the client to bend and pick up objects assesses motor function, not neck stiffness. D: Introducing a painful stimulus is not a standard or appropriate method for examining neck stiffness and rigidity.