Nursing Process Test Bank

Correct Answer: C

Rationale: The correct answer is C: ABG. Monitoring ABG in Guillain-Barre Syndrome patients is crucial as they are at risk for respiratory complications like respiratory failure due to muscle weakness. ABG provides information on oxygenation, ventilation, and acid-base balance. Regular monitoring helps detect early signs of respiratory distress and guide appropriate interventions. A: BUN and creatinine are important for assessing renal function, but they do not directly relate to acute complications in Guillain-Barre Syndrome. B: Hgb and Hct are markers for anemia, which is not a common acute complication in Guillain-Barre Syndrome. D: Serum potassium levels are important, but ABG monitoring takes precedence in patients with Guillain-Barre Syndrome due to the risk of respiratory issues.

Correct Answer: D

Rationale: The correct answer is D: To wash hands frequently. This is important in rhinitis prevention as it helps reduce the spread of viruses and bacteria that can trigger or exacerbate symptoms. Washing hands removes potential allergens and irritants, reducing the risk of rhinitis flare-ups. Choice A is incorrect as blowing the nose is necessary to clear mucus and alleviate symptoms. Choice B is irrelevant to rhinitis prevention. Choice C is not directly related to preventing rhinitis.

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: B

Rationale: The correct answer is B because after developing a plan of care, the nurse must communicate it to all healthcare professionals involved in the patient's care to ensure everyone is aware of the plan and can collaborate effectively. This promotes continuity of care and prevents errors. Choice A is incorrect because the plan of care should not be placed in the chart to avoid tampering; it should be easily accessible for updates. Choice C is incorrect as filing in the administration office is unnecessary for routine care. Choice D is incorrect as sending the plan to quality assurance is not the immediate next step after developing the plan.

Correct Answer: C

Rationale: The correct answer is C: Ineffective cerebral tissue perfusion. In the late stage of AIDS, the client is at risk for neurological complications, including AIDS-related dementia due to decreased blood flow to the brain. This nursing diagnosis takes the highest priority as it directly addresses the client's impaired brain perfusion, which can lead to serious cognitive and functional deficits. Prioritizing this diagnosis ensures timely interventions to optimize cerebral blood flow and prevent further deterioration. Summary: A: Self-care deficient: Bathing/hygiene - important but not the highest priority compared to addressing neurological complications. B: Dysfunctional grieving - while emotional support is essential, it is not the priority when dealing with a life-threatening physiological issue. D: Risk for injury - while important, it is secondary to addressing the underlying cause of the dementia in this scenario.