Nursing Process Test Questions

Correct Answer: C

Rationale: The correct answer is C: Increased risk of respiratory complications. Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis all experience muscle weakness, including respiratory muscles, leading to a higher risk of respiratory complications such as difficulty breathing or respiratory failure. This is due to the involvement of the neuromuscular system in these conditions. Choices A, B, and D are incorrect because they do not directly correlate with the respiratory complications commonly seen in these specific neuromuscular disorders.

Correct Answer: A

Rationale: The correct answer is A because hanging the chest drainage system on the top of the wheelchair backrest ensures that the system remains upright and secured during transportation, reducing the risk of accidental disconnection or leakage. Placing it on the patient's feet (B), hanging it with the IV pole (C), or placing it in the patient's lap (D) can lead to potential complications such as pulling or kinking the drainage tubing, increasing the risk of infection or injury to the patient.

Correct Answer: C

Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting with a broad assessment of the surgical dressing and the type of drainage present, then will progress to more specific assessments based on the findings. This approach allows for a systematic and comprehensive evaluation of the patient's condition by moving from general observations to detailed examinations. Explanation: 1. General assessment: The nurse is initially assessing the overall appearance of the surgical dressing and the type of drainage. 2. Specific assessment: Based on the initial findings, the nurse will proceed to conduct more focused assessments, such as checking for signs of infection, monitoring vital signs, and assessing the surgical site for any complications. Other choices are incorrect: A: Gordon�s Functional Health Patterns - This framework focuses on assessing different aspects of an individual's health patterns, such as activity level, sleep patterns, and coping mechanisms. It is not the most appropriate approach in this situation. B: Activity-exercise pattern assessment - This type of assessment focuses

Correct Answer: A

Rationale: The correct answer is A because postural hypotension is defined as a drop in systolic blood pressure of greater than 20 mmHg or a drop in diastolic blood pressure of greater than 10 mmHg within 3 minutes of standing from a sitting or supine position. Therefore, a drop in systolic pressure greater than 10 mmHg when changing from lying to sitting is indicative of postural hypotension. Choice B is incorrect as postural hypotension is primarily defined by changes in systolic blood pressure, not diastolic. Choice C is incorrect because a drop in diastolic pressure greater than 10 mmHg is not the defining characteristic of postural hypotension. Choice D is not provided.

Correct Answer: A

Rationale: The correct answer is A: administer morphine sulfate as ordered. This is the appropriate nursing intervention because acute abdominal pain is a common symptom of acute pancreatitis, and morphine sulfate is a commonly used medication to relieve severe abdominal pain. Administering morphine sulfate will help alleviate Aling Loida's discomfort and improve her overall well-being. Choice B is incorrect because obtaining daily weights is not directly related to managing acute abdominal pain in this scenario. Choice C is incorrect as maintaining Aling Loida on a high calorie, high protein diet may exacerbate her symptoms due to the acute pancreatitis. Choice D is incorrect as placing her on a supine position may not address the underlying cause of the abdominal pain and could potentially worsen her condition.