Nursing Process Test Bank

Correct Answer: B

Rationale: The correct answer is B because conducting the interview in a quiet environment, like the waiting area with the television turned off, reduces background noise and distractions for the patient with a hearing deficit. This allows for better communication and understanding. A: Conducting the interview in the patient's room with the door closed may still have distractions or noise from outside the room. C: Conducting the interview in the patient's room before administration of pain medication does not address the issue of reducing background noise for better communication. D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional distractions and noise, making it harder for the patient with a hearing deficit to communicate effectively.

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: D

Rationale: The correct answer is D: Pain related to sickle cell crisis. In a sickle cell crisis, the client experiences severe pain due to the sickling of red blood cells, which causes blockages in blood vessels. This pain is the hallmark symptom of sickle cell crisis and is a priority nursing diagnosis. The other choices are incorrect because they do not directly relate to the primary issue of sickle cell crisis. Imbalanced nutrition is not typically a priority during a crisis, disturbed sleep pattern is not a common symptom, and impaired skin integrity is not a prominent concern in sickle cell crisis.

Correct Answer: B

Rationale: The correct answer is B because conducting the interview in a quiet environment, such as the waiting area with the television turned off, minimizes background noise and distractions for a patient with a hearing deficit. This setting allows for better communication and ensures that the patient can hear and understand the nurse clearly. A: Conducting the interview in the patient's room with the door closed may still have background noise from the hallway or other rooms. C: Conducting the interview before administration of pain medication is not relevant to improving communication for a patient with a hearing deficit. D: Conducting the interview in the waiting room while the occupational therapist is working on leg exercises introduces additional noise and distractions, making it difficult for the patient to focus on the conversation.

Correct Answer: D

Rationale: The correct answer is D: An aminoglycoside. Aminoglycosides, such as gentamicin or amikacin, can interact with cisplatin by increasing the risk of nephrotoxicity and ototoxicity. Both cisplatin and aminoglycosides have the potential to cause kidney damage, and when used together, the risk of kidney toxicity is significantly increased. This interaction is due to the additive effects on the kidneys. Therefore, it is crucial to monitor renal function closely and adjust the dosages of these drugs accordingly to prevent severe adverse effects. Summary: A: Erythromycin - Erythromycin is not known to have significant interactions with cisplatin. B: A cephalosporin - Cephalosporins do not typically interact with cisplatin in a clinically significant manner. C: A tetracycline - Tetracyclines are not known to cause significant interactions with