Nursing Process Test Bank

Correct Answer: B

Rationale: The correct answer is B: "Good oral hygiene is needed, including brushing and flossing." This is because phenytoin (Dilantin) can cause gingival hyperplasia, a side effect that leads to overgrowth of gum tissue. Good oral hygiene practices, such as regular brushing and flossing, can help prevent or minimize this side effect. Choice A is incorrect because alcohol is contraindicated while taking phenytoin as it can increase the risk of side effects and decrease the effectiveness of the medication. Choice C is incorrect because medication doses should never be self-adjusted without consulting a healthcare provider, as this can lead to ineffective treatment or potential harm. Choice D is incorrect because the timing of the morning dose in relation to drawing a serum drug level is not relevant to the client's understanding of medication instructions and does not address the specific side effect of gingival hyperplasia associated with phenytoin.

Correct Answer: C

Rationale: The correct answer is C: Receive vaccines against infection. Following a splenectomy, the patient is at an increased risk of infection due to the absence of the spleen's immune function. Vaccines help boost the body's immunity against specific pathogens, reducing the risk of infections. This is crucial for preventing post-splenectomy infections. Now, let's analyze the other choices: A: Avoid showering for 1 week - There is no evidence to support that avoiding showering would prevent infection after a splenectomy. B: Sleep in a semi-fowler�s position - Positioning does not directly impact infection prevention post-splenectomy. D: Stay on antibiotics for life - Long-term antibiotic use can lead to antibiotic resistance and is not recommended unless specifically indicated for a different reason.

Correct Answer: C

Rationale: The correct answer is C because asking the client if they are experiencing pain is a direct action of assessment. This step involves gathering information directly from the client to understand their condition and needs. By asking the client about pain, the nurse is actively assessing the client's well-being. A: The nurse bathing the client is not an action of assessment but rather a task related to providing care. B: The nurse documenting the incident is important for recording the event but does not directly involve assessing the client's condition. D: The nurse removing the wash basin is a task related to the physical care process and does not involve direct assessment of the client's well-being.

Correct Answer: C

Rationale: The correct nursing diagnosis is C: Deficient fluid volume. The patient's symptoms indicate dehydration, as evidenced by tachycardia, increased thirst, decreased urine output, and increased body temperature. This points to a lack of fluid in the body. Option A, adult failure to thrive, does not address the immediate issue of fluid volume. Option B, hypothermia, is incorrect as the patient has an increased body temperature. Option D, nausea, is not a primary issue compared to the symptoms indicating dehydration. Therefore, the correct nursing diagnosis is C: Deficient fluid volume.

Correct Answer: C

Rationale: The correct answer is C. Driving in the car with the windows open exposes the patient to pollen, worsening allergies. Staying indoors on dry, windy days (A) reduces exposure. Refusing to walk outside in spring (B) also minimizes exposure. Working in the garden on sunny days (D) increases pollen exposure. Therefore, choice C is the only action that goes against controlling pollen allergies.