Nursing Process Questions and Answers PDF

Correct Answer: A

Rationale: The correct answer is A because an Ileostomy involves diverting the small intestine to an opening in the abdominal wall, so the urine will not be affected. The pouch collects waste from the small intestine. Nasogastric tube (B) is not typically required for an Ileostomy. Laparoscope (C) is used for visualizing the abdomen, not the bowel. Drinking liquids (D) so soon after surgery can be risky and is not recommended.

Correct Answer: B

Rationale: The correct answer is B: Have him breathe into a paper bag. Breathing into a paper bag helps increase the carbon dioxide levels in the blood, which can help reverse respiratory alkalosis caused by hyperventilation during an anxiety attack. This intervention helps to normalize the blood pH and alleviate symptoms. Incorrect choices: A: Making sure oxygen is administered as ordered is not appropriate for respiratory alkalosis due to hyperventilation. Oxygen therapy can worsen the condition by further reducing carbon dioxide levels. C: Placing the student in a semi-fowler's position does not directly address the primary issue of respiratory alkalosis and anxiety-induced hyperventilation. D: Coughing and deep breathing exercises may exacerbate the hyperventilation and worsen the respiratory alkalosis rather than alleviate the symptoms.

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.

Correct Answer: B

Rationale: The correct answer is B: "Keep the stoma dry." Keeping the stoma dry helps prevent infection and skin irritation. Moisture can lead to fungal growth and skin breakdown. Option A is incorrect because keeping the stoma uncovered can increase the risk of contamination and infection. Option C is incorrect as self-care promotes independence and allows the client to become familiar with the procedure. Option D is incorrect as moisture can lead to skin issues.

Correct Answer: A

Rationale: The correct answer is A: Decreased gastrointestinal motility. This is the defining characteristic because it directly links the cause (pain medication administration) to the effect (constipation). The patient's lack of bowel movement, abdominal distention, and pain are all consequences of decreased gastrointestinal motility. Pain medication slows down the movement of the intestines, leading to constipation. Choices B, C, and D are incorrect because while they are related to the patient's condition, they are not the defining characteristic that connects the cause to the effect in this specific scenario.