Nursing Process Questions

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: D

Rationale: The correct answer is D - Shallow breathing and increasing lethargy. This could indicate a potential complication such as respiratory distress or postoperative infection. Shallow breathing may suggest respiratory compromise, while increasing lethargy could be a sign of systemic infection or inadequate oxygenation. A: Abdominal pain is common postoperatively and can be managed with pain medication. B: Serous drainage from the incision is normal and expected in the early postoperative period. C: Hypoactive bowel sounds are common after abdominal surgery due to anesthesia and manipulation of the bowel; it typically resolves as the patient recovers. In summary, the other options are common postoperative findings, while shallow breathing and increasing lethargy are concerning signs that require immediate attention.

Correct Answer: A

Rationale: The correct answer is A: weight loss. Weight loss is a common symptom of tuberculosis due to the impact of the infection on the body's metabolism and appetite. This symptom is important to recognize as it can be an early indicator of the disease. Dyspnea on exertion (B) is not a common symptom of tuberculosis, as it typically affects the lungs rather than causing difficulty breathing. Increased appetite (C) is not a typical symptom, as TB usually leads to decreased appetite and weight loss. Mental status changes (D) are not directly associated with tuberculosis and are more commonly seen in other conditions affecting the brain. Therefore, weight loss is the most relevant symptom to include in the teaching material for identifying possible cases of tuberculosis.

Correct Answer: C

Rationale: Objective data are measurable and observable facts obtained through physical examination or diagnostic tests. In this case, "Respirations 16" is a quantifiable and observable measurement, making it objective data. It is not influenced by personal interpretation or feelings. The other choices, such as "States 'doesn't feel good'", "Reports a headache", and "Nauseated" are subjective data because they are based on the patient's feelings or experiences, which can vary depending on individual perception and interpretation, making them less reliable for making clinical decisions. By focusing on objective data like "Respirations 16", the nurse can provide a more accurate assessment of the patient's condition.

Correct Answer: B

Rationale: The correct answer is B. The nurse should do a quick assessment to confirm the change in the patient's status, then notify the RN or physician. This is the best response because the nurse needs to immediately assess the patient's condition to ensure prompt intervention if needed. By confirming the change in the patient's status, the nurse can provide the necessary information to the healthcare team for appropriate evaluation and management. The other choices are incorrect because: A does not address the urgency of the situation, C involves unnecessary delay by waiting for the speech therapist, and D is not appropriate as the nurse should be the one assessing and notifying the healthcare team.