Nursing Process Quizlet Questions

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Assessment of neurologic signs establishes baseline for post-op care. 2. Helps detect any changes post-surgery. 3. Enables prompt intervention if any issues arise. 4. Planning activities (B) is not a priority pre-surgery. 5. Enema (C) may not be necessary for all surgeries. 6. Explaining complications (D) is important but not a primary pre-op nursing care.

Correct Answer: C

Rationale: The correct answer is C: Listen and show interest as the client expresses feelings. It is essential for the nurse to actively listen and show empathy towards the client's emotional distress. This approach demonstrates compassion, understanding, and support for the client during a vulnerable moment, which is crucial for the therapeutic relationship. By actively listening, the nurse can validate the client's emotions and provide a safe space for them to express their feelings. This can help the client feel heard and supported, leading to improved emotional well-being. Choices A, B, and D are incorrect: A: Continuing with the bath and telling the client not to worry dismisses the client's emotions and fails to address their underlying feelings of loneliness and isolation. B: Asking for a psychiatric consultation may not be necessary at this point, as the client's emotional distress can be effectively managed through therapeutic communication. D: Stating that the friends' behavior shows they aren't true friends is judgmental and unhelpful, as it does not address

Correct Answer: C

Rationale: The correct answer is C: 500 ml. When someone loses 0.5 kg of weight, it is estimated that about 500 ml of fluid has been lost, as 1 kg of body weight is roughly equivalent to 1 liter of fluid. This fluid loss is due to water loss through sweating, breathing, and urine. Choice A (50 ml) is too small of an amount for a significant weight loss. Choice B (750 ml) is too high and would correspond to a larger weight loss. Choice D (75 ml) is also too small to account for a 0.5 kg weight loss.

Correct Answer: B

Rationale: Step 1: Activity intolerance is defined as insufficient physiological or psychological energy to endure or complete required or desired daily activities. Step 2: In the scenario, the patient experiences shortness of breath when getting out of bed, indicating decreased ability to tolerate physical activity. Step 3: This shortness of breath is a defining characteristic of activity intolerance as it reflects the patient's limited ability to perform activities of daily living. Step 4: Other symptoms like decreased oral intake, decreased oxygen saturation, and productive cough may be related to other health issues but are not specific to activity intolerance. Step 5: Therefore, choice B is the correct answer as it includes a key defining characteristic of activity intolerance, while other choices do not directly relate to the concept.

Correct Answer: A

Rationale: The correct answer is A: Apply zinc oxide to the surrounding skin. This intervention helps create a protective barrier between the irritating drainage or wound compresses and the skin, thus preventing maceration. Zinc oxide has moisture-repelling properties that can help keep the skin dry and reduce the risk of maceration. Choice B (Using a binder) may not address the root cause of maceration and could potentially increase pressure on the wound site. Choice C (Supporting the arm and shoulder with pillows) may provide comfort but does not directly prevent maceration. Choice D (Instructing the client not to shave axillary hair) is unrelated to preventing maceration from irritating drainage or wound compresses.