Nursing Process NCLEX Questions

Correct Answer: C

Rationale: The correct answer is C: Osteoporosis. Long-term corticosteroid therapy, such as prednisone, is known to cause bone loss and increase the risk of osteoporosis. Corticosteroids inhibit bone formation and increase bone resorption, leading to decreased bone density and increased fracture risk, which can manifest as severe back pain. Incorrect choices: A: Hypertension - Corticosteroids can cause fluid retention and sodium retention, leading to hypertension, but it is not typically associated with severe back pain. B: Muscle wasting - Corticosteroids can lead to muscle weakness, but severe back pain is not typically related to muscle wasting. D: Truncal obesity - Corticosteroids can cause weight gain, especially in the trunk area, but this is not directly responsible for severe back pain.

Correct Answer: C

Rationale: The correct answer is C: 0.45% saline. This solution is hypotonic because it has a lower osmolarity compared to the intracellular fluid. It contains fewer solutes than the cells, causing water to move into the cells by osmosis, potentially causing them to swell. Normal saline (A) and Ringer's lactate (B) are isotonic solutions, meaning they have a similar osmolarity to the intracellular fluid and do not cause significant water shifts. 5% dextrose in normal saline (D) is a hypertonic solution, containing more solutes than the cells, leading to water movement out of the cells.

Correct Answer: C

Rationale: Step-by-step rationale for choice C: Angioedema differs from urticaria as it involves deeper swelling in the dermis and subcutaneous tissue, leading to a more profound and firm texture. This contrasts with urticaria, which presents as superficial, raised wheals on the skin. Therefore, option C is correct. Summary of other choices: A: Angioedema is not typically associated with intense itching, so it is not more pruritic than urticaria. B: Angioedema does not have small, fluid-filled vesicles like in allergic contact dermatitis. D: Angioedema tends to last longer than urticaria, making this statement incorrect.

Correct Answer: A

Rationale: The correct answer is A because the "Where is the pain located?" question corresponds to the "P" component in the PQRST assessment, which stands for Provocative/Palliative factors. This question helps identify the specific location of the pain and what triggers or alleviates it. The other choices are incorrect because: - B: "What causes the pain?" corresponds to the "Q" component (Quality of pain), focusing on the characteristics of the pain. - C: "Does it come and go?" corresponds to the "R" component (Region/Radiation of pain), focusing on the pattern and radiation of the pain. - D: "What does the pain feel like?" corresponds to the "S" component (Severity of pain), focusing on the intensity of the pain.

Correct Answer: B

Rationale: The correct answer is B: Respiratory rate of 8 breaths/min. Morphine is an opioid that can cause respiratory depression as a side effect. A respiratory rate of 8 breaths/min indicates hypoventilation, which is a potential adverse effect of morphine. This is a critical finding that requires immediate intervention to prevent respiratory failure or arrest. A: Voiding of 350mL of concentrated urine in 8 hours is not directly related to morphine's adverse effects. Morphine can cause urinary retention, not increased voiding. C: Irregular heart rate of 82 beats/min is within normal range and not a typical adverse effect of morphine. Morphine can cause bradycardia or tachycardia, but not irregular heart rate specifically. D: Pupils constricted and equal is a common side effect of morphine due to its effect on the central nervous system. This finding does not suggest an adverse effect; it is an expected pharmac