ADPIE Nursing Process 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 may experience respiratory muscle weakness, leading to difficulty breathing and an increased risk of respiratory complications such as pneumonia or respiratory failure. This is due to the involvement of the muscles responsible for breathing in these conditions. Progressive deterioration until death (A) is not always the case and varies depending on the condition and individual. Deficiencies of essential neurotransmitters (B) is not a common symptom in these conditions. Involuntary twitching of small muscle groups (D) is not a characteristic symptom of these neurological disorders.

Correct Answer: A

Rationale: The correct answer is A because modifying the care plan during the evaluation phase involves making changes based on the client's response to interventions. By adding a new intervention to address an unmet goal, the nurse demonstrates critical thinking and adaptability in response to the client's needs. This action shows that the nurse is actively assessing and revising the care plan to ensure it is effective in meeting the client's goals. Choice B is incorrect because routine monitoring is part of the assessment and implementation phases, not specifically related to modifying the care plan during evaluation. Choice C is incorrect as administering medication is part of the implementation phase and does not necessarily involve modifying the care plan. Choice D is also incorrect as completing discharge paperwork is typically part of the discharge planning phase, not the evaluation phase where modifications to the care plan are made based on client outcomes.

Correct Answer: A

Rationale: The correct answer is A: Monthly testicular self-examination. This is the best way to detect testicular cancer early because it allows individuals to become familiar with the normal size, shape, and texture of their testicles, making it easier to notice any changes or abnormalities. Self-examination is cost-effective, convenient, and can be done regularly to monitor for any signs of cancer. Annual physician examination (B) may not be frequent enough for early detection. Yearly digital rectal examination (C) is not relevant for detecting testicular cancer. Annual ultrasonography (D) is not recommended as a routine screening tool for testicular cancer.

Correct Answer: B

Rationale: The correct answer is B because it provides specific, measurable, achievable, relevant, and time-bound (SMART) parameters for achieving the outcome. It outlines the calorie intake, meal frequency, and start date, which allows for clear monitoring and evaluation of progress. Choice A is too vague and lacks specificity. Choice C focuses on wound care, not dietary goals. Choice D lacks specificity and a timeframe, making it difficult to measure success. In conclusion, choice B is the best option as it aligns with effective goal-setting principles.

Correct Answer: B

Rationale: The correct answer is B: Presence of flatus. This indicates normal gastrointestinal function post-bowel resection. Flatus production signifies peristalsis and passage of gas through the intestines, indicating that the bowels are working. A, firm abdomen, may indicate distention or ileus, not normal function. C, excessive thirst, is unrelated to bowel function. D, absent bowel sounds, may indicate ileus or bowel obstruction, not normal function.