ADPIE Nursing Process Questions

Correct Answer: D

Rationale: The primary purpose of validation in assessment is to ensure that the data collected is accurate and reliable to plan appropriate nursing care. Validation helps confirm the accuracy of data, identify inconsistencies, and ensure that the information gathered is trustworthy. By verifying the data, nurses can make informed decisions and tailor individualized care plans to meet the patient's needs effectively. Choices A, B, and C are incorrect because they do not directly relate to the purpose of validation in assessment. Choice A focuses on the identification of data, not the purpose of validation. Choice B and C pertain to communication and relationships, which are important but not the primary purpose of validation in the assessment process.

Correct Answer: C

Rationale: The normal range for intraocular pressure (IOP) is approximately 10-21 mm Hg. Choice C has an IOP of 11 mm Hg, falling within this normal range, making it the correct answer. Choices A, B, and D are outside the normal range, with A being too low and B and D being too high, indicating abnormal IOP levels. Choice A (8 mm Hg) is below the normal range, while choices B (25 mm Hg) and D (28 mm Hg) are above the normal range, therefore, they are incorrect answers.

Correct Answer: D

Rationale: The correct answer is D: Cryptorchidism. Cryptorchidism, also known as undescended testicle, is a known risk factor for testicular cancer as the testicle does not descend into the scrotum during fetal development, increasing the risk of cancer development. Testosterone therapy during childhood (A) and early onset of puberty (B) are not directly linked to testicular cancer. Sexually transmitted diseases (C) typically do not increase the risk of testicular cancer. Therefore, choice D is the most relevant risk factor for testicular cancer in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Administer 6L of IV fluid over the first 24 hours. In HHNS, dehydration is severe due to high blood glucose levels causing osmotic diuresis. Rapid infusion of fluid can lead to fluid overload and exacerbate the situation. Administering 6L over 24 hours helps gradually replenish lost fluids without causing circulatory overload. Choice A is incorrect because rapid infusion can lead to fluid overload. Choice C is incorrect because adding dextrose to the solution can further increase blood glucose levels. Choice D is incorrect because administering IV fluids slowly can delay rehydration in a critical situation like HHNS.

Correct Answer: B

Rationale: The correct answer is B: Stool for Clostridium difficile test. In this scenario, the client is experiencing symptoms suggestive of a possible Clostridium difficile infection, a common complication of chemotherapy. The test is crucial to confirm the presence of C. difficile toxins in the stool, which would guide appropriate treatment with antibiotics such as metronidazole or vancomycin. A: Enzyme-linked immunosuppressant assay is not relevant in this context as it is used to measure levels of immunosuppressant drugs, not for diagnosing C. difficile infection. C: Flat palate X-ray of the abdomen is unnecessary and would not provide information about the cause of the symptoms. D: Electrolyte panel and hemogram are important for monitoring overall health status but do not directly address the specific issue of possible C. difficile infection.