Nursing Process Questions and Answers PDF

Correct Answer: A

Rationale: The correct answer is A: Antihistamines. Labyrinthitis is an inner ear condition often caused by inflammation or infection. Antihistamines help reduce symptoms like vertigo and dizziness by decreasing inflammation and fluid buildup in the inner ear. Anti-inflammatories (choice B) may help with inflammation but are not as effective for inner ear conditions. Antispasmotics (choice C) are not typically used for treating labyrinthitis. Antiemetics (choice D) are used to control nausea and vomiting, which can be symptoms of labyrinthitis but do not address the underlying cause.

Correct Answer: A

Rationale: The correct answer is A: Decreased serum sodium level. In SIADH, there is an excessive release of ADH, causing water retention and dilution of sodium in the blood. This leads to hyponatremia. B: Increased blood urea nitrogen and C: Decreased serum creatinine level are not typically associated with SIADH. D: Increased hematocrit is not a typical finding in SIADH, as it is more related to dehydration. Therefore, the most anticipated laboratory test result in a client with SIADH is a decreased serum sodium level due to dilutional hyponatremia.

Correct Answer: D

Rationale: The correct answer is D: Risk for body image disturbance. In the context of Maslow's hierarchy of needs, physiological needs take precedence over psychological needs. For a client in the intensive care unit with congestive heart failure, ensuring physiological needs like airway clearance, urinary elimination, and coping are addressed first is crucial for survival. Body image disturbance is a higher-level psychological need and can be addressed once basic physiological needs are met. Therefore, addressing the risk for body image disturbance would have the lowest priority compared to the other options provided.

Correct Answer: B

Rationale: The correct answer is B because encouraging the patient to do leg exercises within the limits of his traction promotes independence by maintaining muscle strength and mobility. This helps prevent muscle atrophy and promotes circulation. Choice A focuses on pain management but does not directly promote independence. Choice C provides assistance but does not actively involve the patient in self-care. Choice D is important for overall care but does not directly promote independence through active patient involvement.

Correct Answer: D

Rationale: The correct answer is D: Right ventricular hypertrophy. Elevated pulmonary vascular pressures lead to increased resistance in the pulmonary circulation, causing the right ventricle to work harder to pump blood to the lungs. Over time, this can result in hypertrophy of the right ventricle as it adapts to the increased workload. Left atrial atrophy (A) and right atrial atrophy (C) are unlikely as the atria are not directly affected by elevated pulmonary pressures. Left ventricular hypertrophy (B) is not the correct choice as it typically occurs in response to systemic hypertension, not pulmonary hypertension.