Fundamentals of Nursing Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. The nurse is using assessment data to analyze, interpret, and make a judgement about the patient's condition. This process involves critical thinking skills to develop a nursing diagnosis. Choice A (Assigning clinical cues) is incorrect because it refers to identifying specific signs and symptoms. Choice B (Defining characteristics) is incorrect as it pertains to the features of a diagnosed condition. Choice D (Diagnostic labeling) is incorrect because it focuses on naming a specific nursing diagnosis. Diagnostic reasoning encompasses the entire process of analyzing data, making connections, and formulating a nursing diagnosis based on critical thinking.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. The nurse is utilizing assessment data to analyze and interpret the information to develop a nursing diagnosis. This involves critical thinking skills to make conclusions and create a plan of care. A: Assigning clinical cues - This choice is incorrect as it refers to identifying objective and subjective data during assessment, not the process of analyzing and synthesizing data to form a diagnosis. B: Defining characteristics - This choice is incorrect as it typically refers to the specific manifestations or symptoms associated with a particular nursing diagnosis, not the process of diagnosing itself. D: Diagnostic labeling - This choice is incorrect as it refers to the final step in the nursing diagnosis process where the nurse assigns a label to the identified problem, not the overall process of diagnostic reasoning.

Correct Answer: B

Rationale: Correct Answer: B Rationale: Measuring intake and output and recommending increased fluid intake for a client with pyelonephritis is crucial to help flush out infectious microorganisms from the urinary tract. By increasing fluid intake, the client will urinate more frequently, aiding in the removal of bacteria causing the infection. This helps in reducing the bacterial load in the urinary tract and promoting faster recovery. Monitoring intake and output also helps ensure the client is adequately hydrated. Summary of Other Choices: A: Monitoring intake and output is more about assessing hydration status and kidney function rather than the response to therapy. C: Intake and output measurement does not directly determine the location of discomfort in pyelonephritis. D: Monitoring intake and output is not primarily for detecting changes but for ensuring proper fluid balance and aiding in infection clearance.

Correct Answer: C

Rationale: The correct answer is C: Urine output increases. This indicates digoxin's effectiveness as it improves cardiac output by enhancing contraction strength. Increased urine output signifies improved kidney perfusion due to enhanced cardiac function. Option A is incorrect as decreased urine output indicates poor kidney perfusion. Option B is incorrect as digoxin aims to regulate heart rate, not necessarily make it higher than 95. Option D is incorrect as a heart rate lower than 50 could indicate digoxin toxicity.

Correct Answer: C

Rationale: The correct answer is C: To comply with the medication regimen. Teaching the older client with TIA to comply with medication regimen is crucial in preventing further TIAs or strokes. Medications like antiplatelets or anticoagulants are often prescribed to manage TIA. This education empowers the client to actively participate in their own health management. Incorrect choices: A: Not to worry about the symptoms that are part of the normal aging process - This is incorrect as TIA symptoms are not considered a normal part of aging and should not be ignored. B: To admit oneself to a rehabilitation center or a nursing home for rehabilitation - This is incorrect as it is not the primary intervention for managing TIA. D: To observe any changes in the nails and skin - This is incorrect as it is not directly related to managing TIA.