Nursing Process Test Bank

Correct Answer: C

Rationale: Rationale for Correct Answer (C): 1. Paraplegia is a condition where both lower extremities are paralyzed. 2. The prefix "para-" means alongside or beside, indicating that both legs are affected. 3. The nurse would explain to the family that Mr. Gubatan has paralysis in his lower extremities only. 4. This aligns with the medical definition of paraplegia. Summary of Incorrect Choices: A. Upper extremities being paralyzed is not indicative of paraplegia, as paraplegia specifically refers to lower extremity paralysis. B. Both lower and upper extremities being paralyzed is suggestive of quadriplegia, not paraplegia. D. One side of the body being paralyzed describes hemiplegia, not paraplegia.

Correct Answer: C

Rationale: The correct answer is C: Dopamine. Parkinson's disease is primarily caused by a deficiency of dopamine in the brain, leading to the characteristic symptoms of bradykinesia, rigidity, and tremors. Dopamine is a neurotransmitter involved in movement control. Acetylcholine (Choice A) is not directly related to Parkinson's disease, although its imbalance can contribute to other movement disorders. Serotonin (Choice B) and Phenylalanine (Choice D) are not primarily involved in the pathophysiology of Parkinson's disease.

Correct Answer: C

Rationale: The correct answer is C: Maintains skin integrity. During inguinal hernia repair surgery, maintaining skin integrity is crucial to prevent infection and ensure proper wound healing. This outcome focuses on the physical aspect of the surgery and reflects the patient's skin condition postoperatively. Verbalizing fears (A) addresses emotional concerns, demonstrating leg exercises (B) is related to postoperative rehabilitation, and explaining deep breathing exercises (D) targets respiratory function, none of which directly assess the intraoperative outcome of skin integrity.

Correct Answer: B

Rationale: The correct answer is B because it directly reflects the client's progress in physical activity, a key indicator of recovery post-myocardial infarction. Walking 500 meters without chest pain shows improved cardiovascular function and exercise tolerance. Vital signs and lab results from admission (A) are important for initial assessment but not for ongoing evaluation. Physician notes (C) may provide insights but do not directly measure the client's progress. Medications prescribed (D) are important but do not reflect the client's specific improvement in physical activity.

Correct Answer: C

Rationale: The correct answer is C: Memory cells. After recovery from a disease, memory cells are formed as part of the adaptive immune response. These memory cells "remember" the pathogen and can mount a quicker and stronger immune response upon re-exposure. This results in immunity to the disease. Antigens (choice A) are substances that trigger the immune response but do not provide immunity on their own. Complement (choice B) is a group of proteins that enhance the immune response but do not directly lead to immunity. Natural killer cells (choice D) are part of the innate immune system and are not responsible for the specific memory response needed for immunity.