Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A because a nursing diagnosis typically consists of two parts: the problem (Risk for Aspiration) and the related factor (reduced level of consciousness). This format helps clearly identify the client's health issue and its cause. Choice B is incorrect as it refers to a nursing diagnosis focusing on the client's response. Choice C is incorrect as it describes an outcome, not a diagnosis. Choice D is incorrect as a nursing diagnosis should be based on evidence, not made without support. Therefore, the correct choice is A due to the structure and clarity it provides in identifying the client's risk.

Correct Answer: B

Rationale: The correct answer is B (Lifetime dependency on hormone replacement) because after hypophysectomy (removal of the pituitary gland), patients will no longer produce essential hormones like growth hormone, thyroid-stimulating hormone, etc. Therefore, they will require lifelong hormone replacement therapy to maintain normal bodily functions. A: Abnormal distribution of body hair is not directly related to hypophysectomy. C: While fluid intake may be important post-surgery, it is not the primary focus of teaching. D: There is typically no need for repeat surgical procedures after a hypophysectomy, as it is a one-time surgery to address specific issues. In summary, choice B is correct as it directly addresses the long-term implications of the surgery on hormone production and the need for replacement therapy, while the other choices are not directly relevant to the post-operative care of hypophysectomy patients.

Correct Answer: B

Rationale: The correct answer is B: Profound neuromuscular irritability. In hypoparathyroidism, there is a decrease in parathyroid hormone leading to low calcium levels. This can result in neuromuscular irritability such as muscle cramps, spasms, and tingling. Monitoring for neuromuscular symptoms is crucial as they can progress to severe complications like seizures. Choices A, C, and D are incorrect because hypoparathyroidism does not typically present with severe hypotension, excessive thirst, or acute gastritis. Monitoring for signs of hypocalcemia and neuromuscular irritability is essential in managing hypoparathyroidism.

Correct Answer: A

Rationale: The correct answer is A: Inspecting for bleeding or cyanosis. During uterosigmoidostomy, the nurse's critical task is to monitor for any signs of bleeding or cyanosis, which are indicators of potential complications such as hemorrhage or impaired blood flow. This involves observing the surgical site for any abnormal bleeding and assessing the skin color for signs of inadequate oxygenation. Inspecting for symptoms of peritonitis (B) is not directly related to this surgical procedure. Assessing the client's allergy to iodine (C) is important but not a critical task during the procedure. Checking for signs of electrolyte losses (D) is important but not as critical as monitoring for immediate postoperative complications like bleeding or cyanosis.

Correct Answer: C

Rationale: The correct answer is C. Washing feet in hot water is not part of diabetic foot care as it can lead to burns or skin damage. A: Properly fitting shoes help prevent injuries. B: Trimming toenails straight reduces risk of ingrown nails. D: Wearing shoes on hot surfaces protects feet from burns or injuries. Overall, C is incorrect due to its potential harm to the client's feet.