Nursing Process Exam Questions

Correct Answer: A

Rationale: The correct answer is A: Sinusitis. Allergic rhinitis causes inflammation in the nasal passages, leading to congestion and blockage of the sinuses. If the patient does not comply with the treatment regimen, the inflammation can worsen, increasing the risk of developing sinusitis, which is an infection or inflammation of the sinuses. Sinusitis can result in severe pain, pressure, and potentially lead to complications. Summary of other choices: B: Lymphadenopathy - Enlargement of lymph nodes, not directly related to non-compliance with treatment for allergic rhinitis. C: Anaphylaxis - Life-threatening allergic reaction, not a typical consequence of non-compliance with treatment for allergic rhinitis. D: Angioedema - Swelling of deeper layers of skin, usually associated with allergies but not a common outcome of non-compliance with treatment for allergic rhinitis.

Correct Answer: C

Rationale: The correct answer is C because using an electric razor instead of a safety razor demonstrates understanding of the risk of injury associated with thrombocytopenia. This action shows practical application of the teaching to prevent bleeding. Choice A only indicates awareness but not necessarily action. Choice B shows knowledge but not necessarily application. Choice D is related to general healthcare knowledge but not directly linked to bleeding prevention in thrombocytopenia.

Correct Answer: C

Rationale: The correct answer is C: �Are you feeling frightened? I�m here and I will help you.� This response acknowledges the resident�s feelings, offers reassurance, and provides support, focusing on the resident's emotional needs rather than the accuracy of her statements. It shows empathy and validation of her feelings, which can help calm the resident and build trust. Choice A is incorrect because it dismisses the resident's feelings and reality, which can lead to increased distress and confusion. Choice B is incorrect as it doesn't address the resident's emotional state or offer immediate support. Choice D is incorrect as it focuses on correcting the resident's perception rather than providing emotional support, which may lead to further distress.

Correct Answer: B

Rationale: The correct answer is B because the client remains radioactive for a period of time after the implant removal, typically around 10 days. During this time, the nurse should take precautions to limit exposure to radiation. Choice A is incorrect because bodily fluids are not highly radioactive, and proper disposal procedures should be followed. Choice C is incorrect as soiled linens should be handled appropriately to prevent contamination. Choice D is incorrect as bed rest may not be necessary, and mobility should be encouraged within safety guidelines.

Correct Answer: A

Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow. Incorrect choices: B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties. C: James� neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties. D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.