Nursing Process Practice Questions Quizlet

Correct Answer: D

Rationale: The correct answer is D: Pathological fractures. In multiple myeloma, abnormal plasma cells can weaken the bones, leading to fractures even with minimal trauma. The nurse should monitor for signs of bone pain, decreased mobility, and pathological fractures to prevent complications. Uncontrolled bleeding (A) is not typically associated with multiple myeloma. Liver engorgement (B) is more commonly seen in conditions like congestive heart failure or liver disease. Respiratory distress (C) is not a common manifestation of multiple myeloma. Therefore, the nurse should focus on monitoring for pathological fractures as a priority in a patient with multiple myeloma.

Correct Answer: C

Rationale: Rationale for Choice C (Correct Answer): 1. Multiple sclerosis (MS) commonly affects the optic nerve and chiasm. 2. MS is characterized by demyelination of nerves, leading to visual disturbances. 3. Optic nerve involvement results in vision problems, such as blurred vision. 4. Chiasm involvement can cause visual field deficits and color perception changes. Summary of Other Choices: A: Lateral, 3rd, and 4th ventricles - Incorrect. MS primarily affects the central nervous system, not ventricles. B: Pons, medulla, and cerebral peduncles - Incorrect. While these areas are part of the brainstem, they are not commonly affected in MS. D: Above areas - Incorrect. This choice is vague and does not specify any specific areas affected by MS.

Correct Answer: C

Rationale: The correct answer is C, Excessive fluid volume. In Addison's disease, there is a deficiency of cortisol and aldosterone leading to sodium loss and water retention. This imbalance can result in excessive fluid volume. A) Risk for infection is not directly related to Addison's disease. B) Urinary retention is not a common symptom of Addison's disease. D) Hypothermia is not a typical manifestation of Addison's disease.

Correct Answer: D

Rationale: The correct answer is D: Heart. A potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to cardiac arrhythmias and even cardiac arrest. The heart is highly sensitive to potassium levels, as it plays a crucial role in regulating the heart's electrical activity. Elevated potassium levels can disrupt this balance, leading to serious cardiac complications. Summary: A: Lungs - Not directly affected by potassium levels. B: Liver - Not directly affected by potassium levels. C: Kidneys - Kidneys regulate potassium levels but are not the most at risk for dysfunction in this scenario.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Applying antibiotic ointment and placing the mother in reverse isolation are not appropriate for managing vesicles suspected to be herpes simplex virus (HSV) during labor. 2. HSV can be transmitted to the baby during vaginal delivery, leading to serious consequences. 3. Standard precautions should always be maintained to prevent the spread of infections. 4. Preparing for the possibility of a cesarean section and notifying the obstetrician about the vesicles are important steps to protect the baby and staff from potential harm.