Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C because in myasthenia gravis, which is characterized by muscle weakness and fatigue, the administration of edrophonium will temporarily improve muscle strength due to increased availability of acetylcholine at the neuromuscular junction. This improvement should be noted within 30 to 60 seconds after the administration of the medication. Choice A is incorrect because joint pain is not a typical response to edrophonium in the context of myasthenia gravis. Choice B is incorrect because feelings of faintness, dizziness, hypotension, and flushing are more indicative of a cholinergic crisis, which occurs when too much edrophonium is administered. Choice D is incorrect because an increase in muscle strength post-edrophonium administration would not be expected in a client with myasthenia gravis.

Correct Answer: B

Rationale: The correct answer is B: Have patient lie down. When a patient experiences dehiscence (surgical wound separation), lying down helps reduce tension on the wound, minimizing the risk of further tearing. This position also allows the nurse to assess the wound properly. Choice A is incorrect because sitting upright can increase intra-abdominal pressure, worsening the dehiscence. Choice C is incorrect as slowing IV fluids is not a priority in managing dehiscence. Choice D is incorrect because obtaining a sterile suture set should only be done by a healthcare provider and is not the immediate action needed for dehiscence.

Correct Answer: C

Rationale: Objective data in nursing refers to measurable and observable information. Respirations at 16 per minute are a specific, quantifiable measurement that the nurse can directly observe, making it objective data. This information is vital for assessing the patient's respiratory status accurately. Choice A is incorrect because stating "doesn't feel good" is a subjective statement based on the patient's perception and cannot be directly measured or observed. Choice B, reporting a headache, is also subjective as it relies on the patient's description of their symptoms. Choice D, being nauseated, is subjective as well, as it is a symptom reported by the patient and not a quantifiable measurement. In summary, choice C is correct as it represents objective data due to its quantifiable and observable nature, while the other choices are subjective and based on the patient's perceptions or feelings.

Correct Answer: C

Rationale: Correct Answer: C - Diffusion Rationale: Diffusion is the movement of a substance from an area of higher concentration to an area of lower concentration. This process occurs naturally to achieve equilibrium. In the context of fluids and electrolytes, this movement helps maintain balance within the body. Unlike osmosis, which involves the movement of water molecules across a semi-permeable membrane, diffusion applies to the movement of all types of substances. Filtration involves the movement of substances through a barrier under pressure, and active transport requires energy to move substances against a concentration gradient. Therefore, the correct answer is diffusion as it aligns with the principle of movement from high to low concentration for achieving equilibrium.

Correct Answer: C

Rationale: The correct answer is C because in the humoral immune response, B cells are stimulated by T helper cells or macrophages to differentiate into plasma cells that produce antibodies or memory cells. This process involves the production of specific antibodies that target the foreign antigen. Choice A is incorrect because B cells do not phagocytize antigens; instead, they produce antibodies. Choice B is incorrect because T cells do not turn into plasma cells. It is the B cells that differentiate into plasma cells in the humoral immune response. Choice D is incorrect because T cells do not produce antibodies. T cells are involved in cell-mediated immunity, not the humoral immune response.