Nursing Process Quizlet Questions

Correct Answer: A

Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect, especially at higher doses. This is a known adverse reaction to Ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the safety of the client during and after surgery. Incorrect choices: B: Hiccups - Hiccups are not a common side effect of Ketamine administration. C: Extrapyramidal reactions - Ketamine is not known to cause extrapyramidal reactions. D: Respiratory depression - Ketamine typically does not cause respiratory depression, which is more commonly associated with other anesthetics like opioids. Therefore, choice A is the correct answer as it aligns with the known side effects of Ketamine.

Correct Answer: C

Rationale: The correct answer is C because older clients with AIDS have a faster progression of the disease due to age-related changes in the immune system, making them more vulnerable to complications. This results in a greater need for care compared to younger counterparts. Choice A is incorrect as lack of balanced diet and activity does not directly relate to the progression of AIDS. Choice B is incorrect as knowledge about disorders is not the main factor affecting the level of care needed. Choice D is incorrect as adherence to therapy is important but not the main reason older clients need more care.

Correct Answer: D

Rationale: The correct answer is D because it involves a comprehensive approach to addressing the patient's concern. By asking the patient about usual sleep patterns and the onset of having difficulty resting, the nurse can gather important information to assess the potential correlation between the leg cast and restless sleep. This approach demonstrates active listening and shows concern for the patient's well-being. Option A is incorrect because it dismisses the patient's concern and does not address the underlying issue. Option B is also incorrect as it focuses solely on documentation without actively addressing the patient's concern. Option C is not the best choice as it delays addressing the patient's immediate need for help with sleeping, which may impact their overall recovery.

Correct Answer: D

Rationale: The correct answer is D because asking the patient about their usual sleep patterns and onset of difficulty resting is crucial to understand the situation fully. This helps to identify any potential underlying issues contributing to the sleep disturbance. Choice A is incorrect as it dismisses the patient's concerns. Choice B is not as effective as directly addressing the patient's sleep issues. Choice C delays the assessment, potentially missing important information. By choosing answer D, the nurse can gather valuable information to address the patient's sleep problem effectively.

Correct Answer: C

Rationale: Step-by-step rationale for choice C (Serum potassium level of 5.8 mEq/L) being the best to support a diagnosis of Addison's disease: 1. Addison's disease is characterized by adrenal insufficiency, leading to decreased aldosterone secretion. 2. Decreased aldosterone causes hyperkalemia due to impaired potassium excretion. 3. Elevated serum potassium levels above the normal range (3.5-5.0 mEq/L) are a classic finding in Addison's disease. 4. Therefore, a serum potassium level of 5.8 mEq/L strongly supports the diagnosis of Addison's disease. Summary: - Choice A (BUN level): BUN is not specific to Addison's disease and does not directly relate to adrenal function. - Choice B (Serum sodium level): Hyponatremia is a common finding in Addison's disease, but it is not as specific as hyperkalemia. - Choice D (Blood glucose level): Blood glucose