Nursing Process Test Questions

Correct Answer: D

Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.

Correct Answer: D

Rationale: The correct answer is D: Whole grains and meats. Zinc is mainly found in animal-based foods like meats and seafood. Meats, particularly red meats, are rich sources of zinc. Whole grains like wheat, rice, and oats also contain zinc. Legumes (Choice C) are sources of other minerals but not high in zinc. Fruits and vegetables (Choices A and B) are not significant sources of zinc. The correct answer provides the best options for the cancer patient to obtain an adequate amount of zinc for recovery.

Correct Answer: B

Rationale: The correct answer is B: Use pressure relieving devices when the client is in bed. This is because pressure ulcers are a common risk for individuals with neuromuscular disorders due to immobility. Pressure relieving devices such as special mattresses or cushions help redistribute pressure and prevent skin breakdown. Incorrect choices: A: Preventing strenuous exercises is not directly related to preventing skin breakdown in this case. C: Placing the client in Fowler's position may be beneficial for respiratory issues but does not directly address skin integrity. D: Avoiding daily baths with soaps may lead to poor hygiene and does not specifically address the risk of skin breakdown.

Correct Answer: B

Rationale: The correct answer is B: Hematuria. Bacillus Calmette-Guerin (BCG) is commonly used in the treatment of bladder cancer. It works by stimulating the immune system to attack and destroy cancer cells in the bladder. One of the common side effects of BCG instillations is hematuria, which is the presence of blood in the urine. This can occur due to irritation of the bladder lining by the BCG solution, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware of what to expect during treatment. A: Renal calculi - BCG therapy is not commonly associated with the formation of renal calculi. C: Delayed ejaculation - Delayed ejaculation is not a common side effect of BCG therapy. D: Impotence - Impotence is not a common side effect of BCG therapy.

Correct Answer: A

Rationale: The correct answer is A because evaluating a nursing intervention involves collecting data to determine if the goals set for the intervention were achieved. This process helps in assessing the effectiveness of the intervention in meeting the desired outcomes. Option B is incorrect as it refers to the identification of nursing diagnoses for new problems, which is part of the nursing assessment phase, not evaluation. Option C is incorrect as adjusting the care plan to include collaborative interventions is part of the implementation phase, not evaluation. Option D is incorrect as performing client care tasks as per protocol is part of the implementation phase, not evaluation.