Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A: Weight. Monitoring daily weight is crucial in assessing fluid retention and worsening heart failure symptoms. Weight gain can indicate fluid overload, a common complication in heart failure. The other choices (B: Appetite, C: Calorie count, and D: Abdominal girth) are not as directly related to monitoring heart failure severity. Appetite and calorie count may be affected by various factors unrelated to heart failure, while abdominal girth may not provide specific information on fluid status. Monitoring weight allows for early intervention and adjustments in treatment to prevent exacerbation of heart failure symptoms.

Correct Answer: C

Rationale: The correct answer is C because respirations of 16 are measurable and quantifiable, making them objective data. Subjective data, like choices A, B, and D, are based on the patient's feelings or experiences and cannot be measured or observed directly. Choice A is subjective as it relies on the patient's self-report. Choice B is subjective as it describes a symptom reported by the patient. Choice D is subjective as it reflects the patient's feeling of nausea. Objective data is essential for making accurate clinical assessments and decisions.

Correct Answer: C

Rationale: The correct answer is C because in the humoral immune response, B cells are stimulated by T helper cells or macrophages to differentiate into plasma cells that produce antibodies or memory cells. This process involves the production of specific antibodies that target the foreign antigen. Choice A is incorrect because B cells do not phagocytize antigens; instead, they produce antibodies. Choice B is incorrect because T cells do not turn into plasma cells. It is the B cells that differentiate into plasma cells in the humoral immune response. Choice D is incorrect because T cells do not produce antibodies. T cells are involved in cell-mediated immunity, not the humoral immune response.

Correct Answer: B

Rationale: The correct answer is B (Lifetime dependency on hormone replacement) because after hypophysectomy (removal of the pituitary gland), patients will no longer produce essential hormones like growth hormone, thyroid-stimulating hormone, etc. Therefore, they will require lifelong hormone replacement therapy to maintain normal bodily functions. A: Abnormal distribution of body hair is not directly related to hypophysectomy. C: While fluid intake may be important post-surgery, it is not the primary focus of teaching. D: There is typically no need for repeat surgical procedures after a hypophysectomy, as it is a one-time surgery to address specific issues. In summary, choice B is correct as it directly addresses the long-term implications of the surgery on hormone production and the need for replacement therapy, while the other choices are not directly relevant to the post-operative care of hypophysectomy patients.

Correct Answer: A

Rationale: The correct answer is A: Weight. Monitoring daily weight is crucial in assessing fluid retention and worsening heart failure symptoms. Weight gain can indicate fluid overload, a common complication in heart failure. The other choices (B: Appetite, C: Calorie count, and D: Abdominal girth) are not as directly related to monitoring heart failure severity. Appetite and calorie count may be affected by various factors unrelated to heart failure, while abdominal girth may not provide specific information on fluid status. Monitoring weight allows for early intervention and adjustments in treatment to prevent exacerbation of heart failure symptoms.