Nursing Process Practice Questions

Correct Answer: D

Rationale: The correct answer is D: �You must avoid hyperextending your neck after surgery.� This is because hyperextending the neck can put excessive strain on the surgical site, leading to potential complications such as bleeding or injury to the incision. Keeping the neck in a neutral position helps promote healing and reduces the risk of complications. A: �The head of your bed must remain flat for 24 hours after surgery.� - Incorrect. Elevating the head of the bed can help reduce swelling and promote drainage after thyroidectomy. B: �You should avoid deep breathing and coughing after surgery.� - Incorrect. Deep breathing and coughing are important to prevent respiratory complications such as pneumonia. C: �You won�t be able to swallow for the first day or two.� - Incorrect. Swallowing may be difficult initially but should improve gradually after surgery.

Correct Answer: C

Rationale: Rationale: Choice C is correct because antibodies are indeed produced by B-cells as part of the adaptive immune response. B-cells differentiate into plasma cells that produce antibodies to target specific antigens. This process is essential for generating immunity against pathogens. Incorrect Choices: A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity. B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. T-cells directly attack infected cells. D: Lymphocytes can increase during an allergic response, but this does not specifically relate to immunity through antibody production by B-cells.

Correct Answer: B

Rationale: The correct answer is B - Focus on the patient's presenting situation. This is because in the problem-oriented approach, the nurse must first gather data related to the patient's current issue or concern. This initial focus helps in identifying the primary problem, setting priorities, and developing a care plan. Now, let's analyze the other choices: A: Completing questions in chronological order may not be necessary or relevant to addressing the patient's immediate issue. C: Making accurate interpretations of the data comes after data collection, so it is not the first step. D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific and relevant data.

Correct Answer: A

Rationale: The correct answer is A: Infection. After a splenectomy, the client is at risk for infection due to the spleen's role in the immune system. Without the spleen, the body's ability to fight infections is reduced. Infections can be serious and life-threatening. B: Urinary retention is not a typical complication of a splenectomy. C: Congestive heart failure is not directly related to a splenectomy. D: Viral hepatitis is not a common complication of a splenectomy.

Correct Answer: D

Rationale: The correct answer is D because developing a standard formal nursing diagnosis helps nurses focus on the scope of their practice. By identifying specific patient problems and their potential causes, nurses can provide appropriate interventions and evaluate patient outcomes effectively. This process enhances the quality of care delivery and promotes patient safety. A: This is incorrect because nursing diagnoses are not meant to be a language exclusive to nurses but rather a standardized way to communicate patient data. B: This is incorrect as nursing diagnoses are not about distinguishing roles but rather about identifying and addressing patient problems. C: This is incorrect as nursing diagnoses are based on evidence and critical thinking, not solely on intuition.