Fundamentals Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C because it is a realistic goal for a patient with a pelvic fracture on bed rest. The patient needs to use a walker correctly to ambulate safely to the bathroom, which promotes mobility and independence while ensuring safety. This goal is specific, measurable, achievable, relevant, and time-bound. Choice A is incorrect because increasing activity level may not be safe or feasible for a patient with a pelvic fracture. Choice B is incorrect as turning every 2 hours may not be necessary or practical for this patient. Choice D is incorrect as using a sliding board may not be appropriate or necessary for someone with a pelvic fracture.

Correct Answer: A

Rationale: The correct answer is A: maintain a moderate exercise. Exercise helps in maintaining bone density, which is crucial in managing hyperparathyroidism. Moderate exercise can also help in weight management and overall health. Choice B, losing weight, can be helpful but not as crucial as exercise. Choice C, jogging 2 miles per day, may be excessive for some individuals and not necessary for managing hyperparathyroidism. Choice D, resting as much as possible, is not recommended as it can lead to muscle weakness and bone loss, which are already concerns in hyperparathyroidism.

Correct Answer: A

Rationale: The correct answer is A: To detect rejection. After heart transplantation, heart biopsy is performed to monitor for rejection, a common complication. Tissue samples are examined for signs of rejection, such as inflammation. This is crucial for timely intervention to prevent rejection-related complications. Other choices are incorrect: B: Heart functionality is typically assessed through imaging tests like echocardiograms, not biopsy. C: Heart rate monitoring can be done through non-invasive methods like electrocardiograms, not biopsy. D: Checking for heart tumors is not a primary purpose of heart biopsy post-transplantation.

Correct Answer: C

Rationale: The correct answer is C because asking if the client has strained their voice recently is the most relevant question to assess the issue of hopelessness. Voice strain can be a symptom of underlying emotional distress or mental health concerns, which could be contributing to the client's feelings of hopelessness. Choices A, B, and D are unrelated to the client's presenting issue and would not provide valuable information in addressing the problem at hand.

Correct Answer: B

Rationale: The correct answer is B. The nurse should explain that zidovudine (AZT) works by blocking reverse transcriptase, the enzyme necessary for HIV replication. This is the key mechanism of action for AZT in managing HIV. Choice A is incorrect because it provides a partial truth - it does slow the disease process but does not provide the mechanism of action. Choice C is incorrect as it provides incorrect information that there are no medications to stop or cure HIV, which is not true. Choice D is incorrect as it provides misleading information about the drug becoming immune to HIV, which is not the primary concern in this context.