Fundamentals Nursing Process Questions

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: C

Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale (GCS) assesses the level of consciousness by evaluating these three factors. Eye opening assesses the patient's ability to open their eyes spontaneously or in response to stimuli. Verbal response evaluates the patient's ability to speak or respond to verbal stimuli. Motor response assesses the patient's motor function by testing responses to commands or painful stimuli. Choice A is incorrect because it includes "response to pain" instead of "verbal response." Choice B is incorrect because it includes "verbal response" instead of "eye opening." Choice D is incorrect because it includes "eye opening" instead of "verbal response." In summary, the GCS evaluates eye opening, verbal response, and motor response to determine the level of consciousness in patients.

Correct Answer: D

Rationale: The correct answer is D because testing the 4th (trochlear) and 6th (abducens) cranial nerves involves assessing eye movements. The trochlear nerve controls downward and inward eye movement, while the abducens nerve controls lateral eye movement. Asking the patient to follow the finger with their eyes tests the function of both nerves simultaneously. Choices A, B, and C do not specifically target the 4th and 6th cranial nerves, making them incorrect options.

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: C

Rationale: The correct answer is C because administering antiemetic medications like metoclopramide and dexamethasone helps control nausea and vomiting post-chemotherapy. Metoclopramide acts on the gut to reduce nausea, while dexamethasone decreases inflammation and suppresses the vomiting reflex. Choice A focuses on dietary interventions but does not address the physiological cause of nausea. Choice B with breathing exercises may help some clients but does not directly address the nausea and vomiting. Choice D is incorrect as withholding fluids can lead to dehydration, which is not recommended after chemotherapy.