Nursing Process Test Bank

Correct Answer: D

Rationale: The correct answer is D: Pain related to sickle cell crisis. In a sickle cell crisis, the client experiences severe pain due to the sickling of red blood cells, which causes blockages in blood vessels. This pain is the hallmark symptom of sickle cell crisis and is a priority nursing diagnosis. The other choices are incorrect because they do not directly relate to the primary issue of sickle cell crisis. Imbalanced nutrition is not typically a priority during a crisis, disturbed sleep pattern is not a common symptom, and impaired skin integrity is not a prominent concern in sickle cell crisis.

Correct Answer: B

Rationale: The correct answer is B, Middle ear. This is because the middle ear is the most common site for ear infections due to its anatomy, including the Eustachian tube that can easily become blocked, leading to fluid buildup and infection. The outer ear (A) is less susceptible to infections, while the inner ear (C) and semicircular canal (D) are not typically involved in ear infections, as they are more related to balance and hearing functions rather than infection susceptibility.

Correct Answer: B

Rationale: The correct answer is B: Ask her to demonstrate her ability to ambulate. This response is best because it allows the nurse to assess the patient's actual ability to walk safely to the bathroom. By observing her, the nurse can ensure her safety and prevent potential falls. This approach also respects the patient's autonomy while prioritizing her safety. Incorrect responses: A: Allowing her to ambulate unassisted solely for positive self-esteem overlooks the importance of assessing her actual capability and ensuring safety. C: Explaining that assistance will always be available may not address the immediate need for assessment and safety. D: Asking another staff member to assist without assessing the patient's ability herself does not allow the nurse to directly evaluate the patient's safety and independence.

Correct Answer: B

Rationale: The correct answer is B: Pneumonia Carnii. Pulmonary complications in AIDS patients are commonly caused by Pneumocystis jirovecii (previously known as Pneumocystis carinii) pneumonia. This opportunistic infection targets the lungs of immunocompromised individuals, leading to severe respiratory issues. Kaposi's Sarcoma (A) is a cancer commonly seen in AIDS patients but does not directly cause pulmonary complications. Filterable Virus (C) is a vague term and not a known cause of pulmonary issues in AIDS patients. Staphylococcus bacteria (D) can cause infections in AIDS patients but is less common than Pneumocystis jirovecii pneumonia in causing pulmonary complications.

Correct Answer: C

Rationale: The correct answer is C because it shows a positive self-perception and self-acceptance. By choosing the dress based on how it complements her eyes, the patient demonstrates a focus on her own preferences and self-image rather than external validation or criticism. This indicates progress towards accepting her body image. A: Choice A indicates concern about others' opinions, which shows a lack of self-assurance and reliance on external validation. B: Choice B reflects negative body image and self-criticism, indicating a lack of acceptance. D: Choice D is focused on a future event, suggesting avoidance or delay in addressing the current body image issues.