Nursing Process Questions and Answers PDF

Correct Answer: A

Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results provided.

Correct Answer: D

Rationale: The correct answer is D: Peritonitis. Peritonitis is a major complication of peritoneal dialysis due to infection of the peritoneum. It can lead to serious consequences if not treated promptly. The nurse should monitor for signs of peritonitis such as abdominal pain, cloudy dialysate, fever, and increased white blood cell count. Internal hemorrhage (A), hydronephrosis (B), and ecchymosis (C) are not major complications specific to peritoneal dialysis. Internal hemorrhage can occur but is less common. Hydronephrosis is more related to obstruction of the ureters. Ecchymosis refers to bruising and is not directly associated with peritoneal dialysis.

Correct Answer: A

Rationale: The correct answer is A: Raccoon eyes. Basilar skull fracture can result in periorbital bruising, known as raccoon eyes, due to blood pooling in the soft tissues around the eyes. This occurs because the fracture involves the base of the skull near the orbits. Choice B: Amnesia is not a typical symptom of basilar skull fracture. Amnesia may occur in head injuries but is not specific to basilar skull fractures. Choice C: Halo sign is a term used to describe a ring of clear fluid surrounding a blood spot, typically seen in cases of a cerebrospinal fluid leak from the ear or nose, not specific to basilar skull fractures. Choice D: Paresthesia, which refers to abnormal sensations like tingling or numbness, is not a common symptom of basilar skull fractures. It is more associated with nerve damage rather than fractures involving the base of the skull.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Lymphangitis is an inflammation of lymphatic vessels. 2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection. 3. Nurse should notify the physician for further evaluation and treatment. 4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification. 5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification. 6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. Hypercalcemia can lead to dehydration due to increased urine output. 2. Encouraging 3 to 4 L of fluid daily helps prevent dehydration and promote renal excretion of excess calcium. 3. Adequate hydration reduces the risk of kidney stones and other complications associated with hypercalcemia. Summary of why other choices are incorrect: - Choice B (bed rest) does not directly address hypercalcemia complications. - Choice C (cough and deep breathe) is unrelated to managing hypercalcemia. - Choice D (apply heat to painful areas) does not address the underlying cause of hypercalcemia or its complications.