Nursing Process Test Bank

Correct Answer: C

Rationale: The correct answer is C: Vitamin D. In hypoparathyroidism, there is a deficiency of parathyroid hormone leading to low calcium levels. Vitamin D helps in the absorption of calcium from the intestines, thus aiding in maintaining normal calcium levels. It is often prescribed along with calcium supplements to support bone health and prevent complications. Folic acid (A) is not directly related to the treatment of hypoparathyroidism. Potassium (B) is not typically prescribed for this condition and can be harmful in high levels. Iron (D) is not directly involved in calcium metabolism and is not part of the standard treatment regimen for hypoparathyroidism.

Correct Answer: A

Rationale: The correct answer is A: Yearly after age 40. This recommendation aligns with the American Cancer Society guidelines that suggest women should start getting annual mammograms at age 40. This age is important as it is when the risk of breast cancer increases. Yearly screenings help in early detection and better treatment outcomes. The other choices (B, C, D) are incorrect because they do not follow the ACS guidelines. Option B is incorrect as it does not specify an age for starting mammograms. Option C is incorrect as it suggests starting after the first menstrual period, which might be too early. Option D is incorrect as it recommends screenings every 3 years between ages 20 and 40, which is not in line with the ACS recommendation for yearly screenings after age 40.

Correct Answer: D

Rationale: The correct answer is D: Concept map care plan. This type of care plan allows the nurse to visually represent the client's entire situation, including physical, emotional, and social aspects. By using interconnected concepts and relationships, the nurse can see the whole picture and identify potential interventions. Kardex (A) is a concise patient information summary, not comprehensive. Case management (B) focuses on coordinating services but may not capture the holistic view. Critical pathways (C) outline specific steps in care but may not address the client as a whole.

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: 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.