Fundamentals Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C. The nurse can infer that the patient is apprehensive about discharge based on the subjective data of the patient expressing fear of going home and being alone. This indicates the patient may not feel ready to leave the hospital setting. Choice A is incorrect because the patient's fear of going home suggests they may not be comfortable performing dressing changes alone. Choice B is incorrect because there is no information provided to support that the patient can begin retaking all previous medications. Choice D is incorrect as there is no indication that the fear of going home is related to the success of the surgery.

Correct Answer: C

Rationale: The correct answer is C: Axon. The axon is the part of the neuron that transmits impulses away from the cell body towards other neurons, muscles, or glands. Its structure allows for the rapid transmission of electrical signals. Rationale: 1. Dendrites receive signals and transmit them towards the cell body, so A is incorrect. 2. Neurolemma is the outermost layer of a Schwann cell, not a part of the neuron responsible for transmitting impulses, so B is incorrect. 3. The synapse is the junction between two neurons where communication occurs, not a part of the neuron transmitting impulses, so D is incorrect.

Correct Answer: C

Rationale: The correct answer is C: Collaborative problem. The nurse needs to revise this part of the diagnostic statement because impaired physical mobility related to tibial fracture is a nursing diagnosis, not a collaborative problem. Collaborative problems are issues that require both medical and nursing interventions, whereas nursing diagnoses are within the scope of nursing practice. The etiology identifies the cause of the problem (tibial fracture), the nursing diagnosis states the problem (impaired physical mobility), and the defining characteristic is the evidence that supports the diagnosis (inability to ambulate). Therefore, the nurse should revise the part stating collaborative problem as it does not align with the nature of the issue presented in the scenario.

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.

Correct Answer: B

Rationale: The correct answer is B: Pathologic bone fractures. In multiple myeloma, there is an increase in osteoclast activity leading to bone destruction, making patients prone to pathologic fractures. Chronic liver failure (A), acute heart failure (C), and hypoxemia (D) are not directly associated with multiple myeloma pathophysiology. This highlights the importance of understanding the disease process to determine the correct answer.