Nursing Process Questions and Answers PDF

Correct Answer: A

Rationale: The correct answer is A: Position the client flat for at least 3 hrs or as directed by the physician. Rationale: 1. Positioning the client flat helps prevent post-lumbar puncture headache by allowing the CSF to replenish and stabilize the pressure in the spinal canal. 2. The recommended time frame of 3 hours allows for adequate CSF reabsorption and reduces the likelihood of headache. 3. Following physician's direction is crucial to individualize care based on the specific situation. Summary of other choices: B: Encouraging fluid intake is generally good practice but may not directly alleviate post-lumbar puncture headache. C: Keeping the room well lit and playing soothing music may not address the physiological cause of the client's symptoms. D: Ambulation and leg exercises are not recommended immediately post-lumbar puncture as they may exacerbate dizziness and headache.

Correct Answer: B

Rationale: The correct answer is B: Cerebral edema. Hypernatremia is an elevated sodium level in the blood, which can lead to osmotic shifts causing water to move out of cells, including brain cells. This can result in cerebral edema, potentially leading to neurological complications. Incorrect choices: A: Red blood cell crenation - This occurs in hypertonic solutions, not hypernatremia. C: Red blood cell hydrolysis - Hypernatremia doesn't directly cause red blood cell hydrolysis. D: Renal shutdown - Hypernatremia can stress the kidneys, but it doesn't typically lead to renal shutdown.

Correct Answer: B

Rationale: The correct answer is B: PTT (Partial Thromboplastin Time) because it specifically measures the effectiveness of heparin therapy by assessing the intrinsic pathway of the coagulation cascade. A prolonged PTT indicates that heparin is achieving the desired anticoagulant effect. A: INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin. C: PT (Prothrombin Time) is also used to monitor warfarin therapy. D: Bleeding time is not typically used to monitor heparin therapy and is more focused on platelet function rather than coagulation factors.

Correct Answer: A

Rationale: The correct answer is A because an Ileostomy involves diverting the small intestine to an opening in the abdominal wall, so the urine will not be affected. The pouch collects waste from the small intestine. Nasogastric tube (B) is not typically required for an Ileostomy. Laparoscope (C) is used for visualizing the abdomen, not the bowel. Drinking liquids (D) so soon after surgery can be risky and is not recommended.

Correct Answer: B

Rationale: The correct answer is B: Patient expectations. During a nursing health history, the nurse focuses on gathering information about the patient's health concerns, medical history, lifestyle, and expectations for their care. Addressing patient expectations is crucial for providing patient-centered care and establishing a therapeutic relationship. The other choices are incorrect because: A: Nurse's concerns are not the primary focus of a nursing health history. C: Current treatment orders are important but are typically addressed during a physical assessment or when implementing care. D: Nurse's goals for the patient are important but should be developed in collaboration with the patient based on their needs and preferences.