Nursing Process Quizlet Questions

Correct Answer: A

Rationale: The correct answer is A: Reassess the patient and situation. The nurse should reassess to determine the cause of the pressure ulcer, evaluate the effectiveness of the current turning schedule, and identify any contributing factors. This allows for a more targeted intervention plan. B: Incorrect. Simply increasing the frequency of turning may not address the underlying issue causing the pressure ulcer. C: Incorrect. Delegating turning to nursing assistive personnel without reassessment may not address the root cause of the pressure ulcer. D: Incorrect. Applying medication without reassessment may not address the underlying cause of the pressure ulcer and could potentially worsen the condition.

Correct Answer: B

Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a client with a cerebellar brain tumor may experience impaired balance due to the cerebellum's role in coordinating voluntary movements and maintaining balance. Impaired balance increases the risk for falls and other injuries. Visual field deficits, difficulty swallowing, and psychomotor seizures are not directly related to the cerebellum's functions in balance and coordination. Therefore, these choices are incorrect for this specific nursing diagnosis.

Correct Answer: D

Rationale: The correct answer is D: Preventing bone injury. In multiple myeloma, bone lesions are common due to bone destruction by abnormal plasma cells. Preventing bone injury is crucial to avoid fractures and bone pain. This can be achieved through careful handling, fall prevention, and avoiding activities that may increase the risk of bone damage. Monitoring respiratory status (A) is not the priority in multiple myeloma. Balancing rest and activity (B) is important but not as critical as preventing bone injury. Restricting fluid intake (C) is not typically necessary unless there are specific indications like renal issues.

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

Correct Answer: D

Rationale: The correct answer is D: Ask the patient about usual sleep patterns and the onset of having difficulty resting. Rationale: 1. Establish rapport: Asking about usual sleep patterns shows empathy and builds rapport. 2. Holistic assessment: Understanding sleep patterns helps identify potential issues beyond the leg cast. 3. Gather information: Knowing the onset of sleep difficulty can reveal underlying causes. 4. Patient-centered care: Addressing sleep concerns aligns with patient needs. Incorrect answers: A: Focusing solely on the leg and cast disregards the patient's holistic well-being. B: Documenting without addressing the patient's concern neglects the opportunity for intervention. C: Delaying assessment till the next shift can worsen the patient's condition and delay appropriate care.