Nursing Process Test Bank

Correct Answer: B

Rationale: The correct answer is B: The waiting area with the television turned off. This choice eliminates potential distractions, allowing the patient with a hearing deficit to focus on the interview. Noise from the television can interfere with communication. Other choices are incorrect because: A) The closed door may block out external noise, but the patient's room could still have distractions. C) Administering pain medication can affect the patient's alertness and ability to communicate effectively. D) The waiting room with occupational therapy activities can be noisy and distracting. Conducting the interview in a quiet waiting area ensures optimal communication and understanding.

Correct Answer: B

Rationale: The correct answer is B: The waiting area with the television turned off. This setting provides a quiet environment, minimizing distractions for the patient with a hearing deficit. It allows the nurse to communicate effectively by speaking clearly and facing the patient directly. Option A is incorrect because a closed door may not be enough to reduce background noise. Option C is incorrect as pain medication may affect the patient's ability to concentrate. Option D is incorrect because the occupational therapist working on leg exercises may create additional noise and distractions.

Correct Answer: B

Rationale: The correct answer is B because it indicates a confrontational and potentially disrespectful attitude towards the nurse. This response does not promote a collaborative and respectful communication between the daughter and the nurse. In a healthcare setting, it is important for family members to communicate effectively and respectfully with the healthcare team to ensure the best care for the patient. A: This statement shows understanding and acceptance of the symptoms of the disease, indicating good knowledge. C: This statement shows willingness to help the patient with tasks he cannot do for himself, which is a positive and caring attitude. D: This statement shows consideration for the patient's needs by planning to turn off the TV when moving to another room, which is appropriate.

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: Rationale for Choice C (Correct answer): - In type II DM, there is some insulin present but it is insufficient to meet the body's needs. - Without sufficient insulin, the body turns to breaking down protein and fatty acids for energy. - This leads to the formation of ketones, which can lead to diabetic ketoacidosis (DKA). - Therefore, the primary reason a type II diabetic does not usually develop DKA is due to insufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs. Summary of other choices: - Choice A is incorrect because there is some insulin available in type II DM, though it may be insufficient. - Choice B is incorrect as type II diabetics do have fat and protein reserves. - Choice D is incorrect as insufficient serum glucose concentrations do not directly relate to the development of DKA in type II DM.