Nursing Process Questions

Correct Answer: B

Rationale: The correct answer is B: An above-normal anti-deoxyribonucleic acid. In SLE, the body produces antibodies against its own DNA, leading to the presence of anti-dsDNA antibodies. Elevated levels of anti-dsDNA antibodies are specific to SLE, confirming the diagnosis. A: Increased total serum complement levels are seen in SLE due to complement activation but are not specific to SLE. C: Negative antinuclear antibody test is not consistent with SLE, as ANA positivity is common in SLE. D: Negative lupus erythematosus cell test is not specific to SLE as lupus erythematosus cells are not always present.

Correct Answer: D

Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates as it directly addresses the underlying physiological issue of impaired gas exchange due to alveolar-capillary membrane changes. The infiltrates indicate infection and inflammation in the lower lobes, leading to difficulty in oxygen and carbon dioxide exchange. This diagnosis aligns with the patient's medical condition and helps guide nursing interventions focused on improving oxygenation. Choice A is incorrect because ineffective breathing pattern is a broad diagnosis that does not specifically address the gas exchange issue seen in pneumonia. Choice B is incorrect as the risk for infection is already present with the diagnosis of pneumonia and does not directly address the patient's current respiratory status. Choice C is incorrect as dehydration is not the primary concern in a patient with pneumonia and lower lobe infiltrates.

Correct Answer: A

Rationale: The correct answer is A, the 50-year-old with an ileostomy, should be monitored most closely for dehydration. Patients with an ileostomy have a higher risk of dehydration due to increased fluid loss through the stoma. Monitoring their fluid intake, output, electrolyte levels, and signs of dehydration is crucial to prevent complications. The other choices are less likely to experience severe dehydration compared to the patient with an ileostomy. The 72-year-old with diabetes mellitus may be at risk for dehydration, but it is not as high a risk as the patient with an ileostomy. The 19-year-old with chronic asthma and the 28-year-old with a broken femur are not as directly related to dehydration compared to the patient with an ileostomy.

Correct Answer: D

Rationale: Correct Answer: D - Lubricating eye drops Rationale: Lubricating eye drops help prevent complications such as corneal abrasions in patients with Bell's Palsy by keeping the eye moist and preventing dryness. Bell's Palsy can cause difficulty in closing the eye properly, leading to dryness and potential damage to the cornea. Using lubricating eye drops helps maintain eye health. Summary of Incorrect Choices: A: Megavitamin therapy - Not directly related to preventing complications in Bell's Palsy. B: Application of ice to the affected area - Ice may not address eye dryness or prevent corneal abrasions. C: Elastic bandages - Not relevant to preventing complications associated with Bell's Palsy.

Correct Answer: B

Rationale: The correct answer is B because it addresses the importance of notifying the physician about a painless lump at the top of the chest incision, which could indicate a serious complication like a seroma or hematoma. This is crucial for early detection and intervention. A is incorrect because showers are generally allowed after cardiac surgery as long as the incisions are kept clean and dry. C is incorrect because support hose or elastic stockings are typically recommended to be worn during the day and removed at night to prevent swelling and promote circulation. D is incorrect because resuming sexual relations after cardiac surgery should be based on individual recovery and should be discussed with the healthcare provider, rather than a standard timeframe.