Nursing Process Questions and Answers PDF

Correct Answer: A

Rationale: The correct answer is A: in a semi-fowler's position. This position helps to improve ventilation and oxygenation by allowing the unaffected lung to expand fully. It also prevents further compression of the affected lung. Trendelenburg position (B) could worsen the pneumothorax by causing more pressure on the affected lung. Prone position (C) is not recommended as it can further compress the affected lung. Placing the patient on the right side (D) would not be beneficial in this case as it does not facilitate lung expansion on the affected side.

Correct Answer: B

Rationale: The correct answer is B: PTT (Partial Thromboplastin Time) because it specifically measures the effectiveness of heparin therapy by assessing the intrinsic pathway of the coagulation cascade. A prolonged PTT indicates that heparin is achieving the desired anticoagulant effect. A: INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin. C: PT (Prothrombin Time) is also used to monitor warfarin therapy. D: Bleeding time is not typically used to monitor heparin therapy and is more focused on platelet function rather than coagulation factors.

Correct Answer: A

Rationale: The correct answer is A: Vasopressin (Pitressin Synthetic). In diabetes insipidus, there is a deficiency of ADH (antidiuretic hormone), leading to excessive urination and thirst. Vasopressin is a synthetic form of ADH that helps retain water by reducing urine output. Administering vasopressin helps manage the symptoms of diabetes insipidus. B: Regular insulin is used to manage diabetes mellitus, not diabetes insipidus. C: Furosemide is a diuretic used to increase urine output, which would worsen the symptoms of diabetes insipidus. D: 10% dextrose is a form of glucose and is not indicated in the treatment of diabetes insipidus.

Correct Answer: C

Rationale: The correct answer is C: fat embolism syndrome related to femur fracture. Fat embolism syndrome occurs when fat globules enter the bloodstream and travel to the lungs, causing respiratory distress. In this case, the patient's femur fracture likely led to fat embolism, explaining her dyspnea, tachypnea, crackles, and thick sputum. Choices A, B, and D do not align with the patient's presentation and history, making them incorrect. Choice A suggests smoke inhalation, which is not supported by the scenario. Choice B mentions pneumonia from bedrest, which is not a common complication of immobility. Choice D proposes hypovolemic shock from multiple trauma, which does not explain the respiratory symptoms and sputum production observed in the patient.

Correct Answer: B

Rationale: The correct answer is B because Toni's behavior of minimizing her visual problems, focusing on future goals, seeking information about job opportunities, and expressing desire for more children reflects coping mechanisms used to deal with the exacerbation of her illness. This behavior suggests that she is trying to maintain a sense of normalcy and control in the face of her health challenges. A: Inappropriate euphoria is excessive happiness or excitement, which is not evident in Toni's behavior. C: Remission phase typically involves a decrease in symptoms, which is not reflected in Toni's situation. D: Realistic for her current level of physical functioning does not explain her behavior as coping mechanisms.