ADPIE Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C (600ml/24hr) because insensible fluid losses in an afebrile person are typically around 600ml per 24 hours. Insensible losses include water lost through the skin as sweat and through the lungs during respiration. These losses are not easily quantifiable but are estimated to be around 600ml/day in normal circumstances. Choices A, B, and D are incorrect because they are either too low (A and B) or too high (D) compared to the normal range of insensible fluid losses. Selecting C as the correct answer is based on the understanding of physiological principles related to fluid balance and normal body functions.

Correct Answer: B

Rationale: The correct answer is B: Acute pain. NANDA-I (North American Nursing Diagnosis Association International) approves standardized nursing diagnoses to guide nursing care. Acute pain is a NANDA-I approved diagnosis as it helps identify and address a patient's pain experience. It is specific, measurable, and relevant for care planning. Sore throat (A) is a symptom, not a diagnosis. Sleep apnea (C) and heart failure (D) are medical conditions, not nursing diagnoses. The focus of nursing care plans is on identifying patient responses to health conditions, which is why acute pain is the most appropriate choice.

Correct Answer: C

Rationale: The correct answer is C: Disturbed body image related to the incision scar. This nursing diagnosis is appropriate as the client's concern about wearing a scarf post-surgery indicates a potential disturbance in body image due to the visible scar. The nurse should address the client's emotional response and offer support to help cope with the change in appearance. A: Risk for impaired physical mobility due to surgery - This choice is not directly related to the client's worry about wearing a scarf and focuses more on physical limitations post-surgery. B: Ineffective denial related to poor coping mechanisms - This choice does not address the specific body image concern expressed by the client. D: Risk of injury related to surgical outcomes - This choice does not address the client's emotional response to the scar and focuses on physical safety risks instead.

Correct Answer: D

Rationale: The correct answer is D: Cryptorchidism. Cryptorchidism, also known as undescended testicle, is a known risk factor for testicular cancer as the testicle does not descend into the scrotum during fetal development, increasing the risk of cancer development. Testosterone therapy during childhood (A) and early onset of puberty (B) are not directly linked to testicular cancer. Sexually transmitted diseases (C) typically do not increase the risk of testicular cancer. Therefore, choice D is the most relevant risk factor for testicular cancer in this scenario.

Correct Answer: B

Rationale: The correct answer is B because performing Valsalva maneuver can lead to a sudden drop in blood pressure, causing the client to lose consciousness. This occurs due to the increased intra-abdominal pressure leading to decreased venous return to the heart. Choices A, C, and D are incorrect as they do not accurately reflect the consequences of Valsalva maneuver. Option A stating that the client's blood pressure will decrease momentarily is incorrect as it actually increases initially. Option C suggesting that the client may suffer from a myocardial infarction is incorrect as Valsalva maneuver does not directly cause heart attacks. Option D implying that the client's blood pressure will increase momentarily is also incorrect as the immediate effect is a rise followed by a significant drop.