Fundamentals of Nursing Nursing Process Questions

Correct Answer:

Rationale: Correct Answer: A: The patient will ambulate in the hallway twice this shift using crutches correctly. Rationale: 1. This choice outlines a specific nursing intervention - ambulating with crutches. 2. It includes clear actions for the patient to ambulate and specifies using crutches correctly. 3. It addresses the patient's physical mobility needs actively. 4. It focuses on promoting independence and functional ability. Summary of other choices: B: This choice includes the nursing diagnosis and the plan but lacks the specificity of the correct answer. C: This choice includes the nursing diagnosis and specifies the use of crutches but lacks the clarity of correct implementation. D: This choice only identifies the patient's condition without providing a specific nursing intervention.

Correct Answer: C

Rationale: The correct answer is C: He walked home in a cold rain. Walking in cold rain can lead to vasoconstriction, which impairs blood flow, increasing the likelihood of a sickle cell crisis in individuals with sickle cell disease. This can cause red blood cells to sickle and block blood vessels, leading to pain and tissue damage. Choices A, B, and D do not directly affect the physiology of sickle cell disease and are less likely to trigger a crisis.

Correct Answer: B

Rationale: The correct answer is B: Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing. This nursing diagnosis takes highest priority for a client with hyperparathyroidism because the client is at risk for skin breakdown due to edema, skin fragility, and poor wound healing caused by the condition. Skin integrity is crucial for preventing infection and promoting overall health. Choice A is incorrect because hyperparathyroidism is not related to thyroid hormone excess, but rather to parathyroid hormone excess. Choice C is incorrect because body image disturbance is not the highest priority compared to the risk of skin breakdown. Choice D is incorrect because hyperparathyroidism typically leads to hypercalcemia and not imbalanced nutrition related to thyroid hormone excess.

Correct Answer: A

Rationale: The correct answer is A: Hypertension. In hypovolemia, the body compensates by increasing heart rate (B: Tachycardia) to maintain perfusion, decreasing urine output (C: Oliguria) to conserve fluid, and increasing respiratory rate (D: Tachypnea) to improve oxygenation. Hypertension is not a typical compensatory response to hypovolemia; instead, blood pressure tends to decrease due to reduced circulating volume. Therefore, hypertension is the symptom that would not be expected in a patient with hypovolemic shock.

Correct Answer: B

Rationale: Step 1: Providing a solution of hydrogen peroxide and water as a mouth rinse helps in reducing the pain of stomatitis by promoting oral hygiene and preventing infections. Step 2: Hydrogen peroxide has antimicrobial properties that can help in reducing bacteria in the mouth, which can worsen stomatitis. Step 3: Rinsing with this solution can also help in cleansing the oral mucosa and reducing inflammation, thereby decreasing pain. Step 4: This intervention directly addresses the nursing diagnosis of impaired oral mucous membrane and is focused on symptom management. Summary: A: Recommending the client to discontinue chemotherapy is not a feasible option as it is essential for treating cancer. C: Monitoring platelet and leukocyte counts is important but does not directly address the pain of stomatitis. D: Checking for signs and symptoms is necessary but does not provide direct relief for the pain of stomatitis.