ADPIE Nursing Process Questions

Correct Answer: A

Rationale: Rationale for Correct Answer (A): The nurse's best response is to inform the pregnant woman that all pregnant women must have an HIV test. This is because HIV testing is a standard part of prenatal care to prevent mother-to-child transmission. It is crucial to detect HIV early to provide appropriate treatment and prevent transmission to the baby. Summary of Incorrect Choices: B: This response could lead to misinformation and potentially harm the patient and her baby. HIV testing is recommended for all pregnant women regardless of risk factors. C: While governmental guidelines may vary, it is essential for all pregnant women to undergo HIV testing to ensure the health of both the mother and the baby. D: While it is important to provide counseling and involve the patient in decision-making, in the case of HIV testing during pregnancy, it is a standard procedure that should be offered to all pregnant women to safeguard their health and that of their baby.

Correct Answer: B

Rationale: The correct answer is B: Acute pain. The NANDA-I (North American Nursing Diagnosis Association International) approved diagnosis must meet specific criteria related to patient assessment data, defining characteristics, and related factors. Acute pain is a well-defined nursing diagnosis with specific defining characteristics and related factors, making it a suitable and approved option for inclusion in a patient's care plan. Sore throat, sleep apnea, and heart failure do not meet the criteria for a NANDA-I approved diagnosis as they lack the specificity and comprehensive assessment data required for a nursing diagnosis.

Correct Answer: A

Rationale: The correct answer is A because hepatitis A is caused by a virus from the Picornaviridae family, not the enterovirus family. Hepatitis A spreads through contaminated food or water, not through sexual contact. It is true that hepatitis A occurs worldwide in areas with poor sanitation, but the virus is not from the enterovirus family. Choices B, C, and D are incorrect because they all pertain to hepatitis A characteristics.

Correct Answer: C

Rationale: The correct answer is C: Turn frequently every 2 hours. This helps redistribute pressure, preventing constant pressure on one area and reducing the risk of developing pressure ulcers. Turning every 2 hours promotes circulation and relieves pressure points. A: Massaging reddened areas can worsen the condition by increasing friction and pressure. B: While a special water mattress can help in preventing pressure ulcers, turning frequently is more effective. D: Keeping the skin clean and dry is important for overall skin health but may not directly prevent pressure ulcers.

Correct Answer: C

Rationale: The correct answer is C: Toilet the patient according to his pre-illness schedule, whether or not he feels the urge. This intervention helps establish a routine for bowel movements, which can aid in reducing episodes of bowel incontinence. By following the patient's pre-illness schedule, the nurse can help regulate bowel movements and prevent accidents. A: Asking the patient frequently if he has to have a bowel movement may not address the underlying issue of bowel incontinence. B: Placing incontinence pads on the patient's bed and chair is a reactive measure and does not address the root cause of the issue. D: Taking care not to embarrass the patient when incontinent episodes occur is important for emotional support but does not directly address reducing episodes of bowel incontinence.