Nursing Process Test Bank

Correct Answer: B

Rationale: The correct answer is B: Teach him to perform Kegel's exercises 10 to 20 times per hour. This is the appropriate action because Kegel's exercises help strengthen the pelvic floor muscles, which can improve urinary control and reduce dribbling post-TURP. Restricting fluid intake (A) is not necessary and may lead to dehydration. Reinserting the Foley catheter (C) is not recommended as it can increase the risk of infection. Reassuring the patient (D) without providing any intervention is not addressing the issue. Teaching Kegel's exercises is the most effective and non-invasive approach to manage post-TURP dribbling.

Correct Answer: B

Rationale: The correct answer is B: Ask her to demonstrate her ability to ambulate. This response is best because it allows the nurse to assess the patient's actual ability to walk safely to the bathroom. By observing her, the nurse can ensure her safety and prevent potential falls. This approach also respects the patient's autonomy while prioritizing her safety. Incorrect responses: A: Allowing her to ambulate unassisted solely for positive self-esteem overlooks the importance of assessing her actual capability and ensuring safety. C: Explaining that assistance will always be available may not address the immediate need for assessment and safety. D: Asking another staff member to assist without assessing the patient's ability herself does not allow the nurse to directly evaluate the patient's safety and independence.

Correct Answer: B

Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, which are signs and symptoms that support the diagnosis. This helps to differentiate it from other types of diagnoses such as risk, possible, or wellness diagnoses. Risk nursing diagnoses predict potential problems, possible nursing diagnoses lack sufficient data for validation, and wellness diagnoses focus on promoting health rather than addressing current health issues. Therefore, only the actual nursing diagnosis is confirmed by the presence of observable defining characteristics.

Correct Answer: C

Rationale: The correct answer is C: providing for frequent rest periods. This intervention is essential for a client with radiation-induced thrombocytopenia to prevent further platelet depletion and reduce the risk of bleeding episodes. Rest periods help conserve energy and minimize physical exertion, which can trigger bleeding in thrombocytopenic clients. Rationale: 1. Administering aspirin (choice A) is contraindicated in thrombocytopenia as it can further decrease platelet count and increase the risk of bleeding. 2. Inspecting the skin for petechiae (choice B) is important but not as crucial as providing rest periods in managing thrombocytopenia. 3. Placing the client in strict isolation (choice D) is not necessary for radiation-induced thrombocytopenia unless there are other specific infectious concerns. In summary, providing frequent rest periods is the most appropriate intervention to manage radiation-induced thrombocytopenia, promoting patient

Correct Answer: D

Rationale: The correct answer is D: Deficient knowledge. This nursing diagnosis is appropriate because educating the patient about hypertension, its management, lifestyle modifications, and medication adherence is crucial in improving outcomes. Activity intolerance (A) and impaired physical mobility (B) are not typically primary focuses for hypertension but may be secondary concerns. Ineffective airway clearance (C) is unrelated to hypertension. Therefore, D is the most relevant option for addressing the patient's needs.