Fundamentals Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is based on the patient's subjective feelings and concerns, which are important to address for a safe discharge. Choices A and B are incorrect as they assume the patient's readiness for independent tasks without considering their emotional state. Choice D is incorrect as there is no objective data provided to support the assumption that the surgery was not successful. It is important for the nurse to acknowledge and address the patient's emotional needs before discharge.

Correct Answer: C

Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient�s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.

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.

Correct Answer: C

Rationale: The correct answer is C: Comparing the patient�s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia. Explanation of why other choices are incorrect: A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes. B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea. D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.

Correct Answer: A

Rationale: The correct answer is A: Nystagmus. A phenytoin blood level of 35 mcg/ml is above the therapeutic range (usually 10-20 mcg/ml). Excessive levels can lead to symptoms such as nystagmus, which is an involuntary eye movement commonly seen with phenytoin toxicity. Nystagmus is a known side effect of phenytoin overdose. Choices B and C are incorrect because a level of 35 mcg/ml is not within the normal therapeutic range, so symptoms would be expected. Choice D, Slurred speech, is not typically associated with phenytoin toxicity.