Nursing Process Test Bank

Correct Answer: C

Rationale: The correct nursing diagnosis is C: Deficient fluid volume. The patient's symptoms indicate dehydration, as evidenced by tachycardia, increased thirst, decreased urine output, and increased body temperature. This points to a lack of fluid in the body. Option A, adult failure to thrive, does not address the immediate issue of fluid volume. Option B, hypothermia, is incorrect as the patient has an increased body temperature. Option D, nausea, is not a primary issue compared to the symptoms indicating dehydration. Therefore, the correct nursing diagnosis is C: Deficient fluid volume.

Correct Answer: C

Rationale: Rationale for Choice C (Correct answer): - In type II DM, there is some insulin present but it is insufficient to meet the body's needs. - Without sufficient insulin, the body turns to breaking down protein and fatty acids for energy. - This leads to the formation of ketones, which can lead to diabetic ketoacidosis (DKA). - Therefore, the primary reason a type II diabetic does not usually develop DKA is due to insufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs. Summary of other choices: - Choice A is incorrect because there is some insulin available in type II DM, though it may be insufficient. - Choice B is incorrect as type II diabetics do have fat and protein reserves. - Choice D is incorrect as insufficient serum glucose concentrations do not directly relate to the development of DKA in type II DM.

Correct Answer: D

Rationale: The correct answer is D because a multilumen pulmonary artery catheter can provide detailed information about preload, afterload, and cardiac output. Preload refers to the volume of blood in the ventricles at the end of diastole, afterload is the resistance the heart has to overcome to eject blood, and cardiac output is the amount of blood pumped by the heart per minute. This catheter allows for direct measurement of these parameters by monitoring pressures in the pulmonary artery. Choices A, B, and C are incorrect individually as they do not encompass the full range of information that can be obtained with a multilumen pulmonary artery catheter.

Correct Answer: B

Rationale: The correct answer is B, Middle ear. This is because the middle ear is the most common site for ear infections due to its anatomy, including the Eustachian tube that can easily become blocked, leading to fluid buildup and infection. The outer ear (A) is less susceptible to infections, while the inner ear (C) and semicircular canal (D) are not typically involved in ear infections, as they are more related to balance and hearing functions rather than infection susceptibility.

Correct Answer: B

Rationale: The correct answer is B: "Good oral hygiene is needed, including brushing and flossing." This is because phenytoin (Dilantin) can cause gingival hyperplasia, a side effect that leads to overgrowth of gum tissue. Good oral hygiene practices, such as regular brushing and flossing, can help prevent or minimize this side effect. Choice A is incorrect because alcohol is contraindicated while taking phenytoin as it can increase the risk of side effects and decrease the effectiveness of the medication. Choice C is incorrect because medication doses should never be self-adjusted without consulting a healthcare provider, as this can lead to ineffective treatment or potential harm. Choice D is incorrect because the timing of the morning dose in relation to drawing a serum drug level is not relevant to the client's understanding of medication instructions and does not address the specific side effect of gingival hyperplasia associated with phenytoin.