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: B

Rationale: The correct answer is B because the patient being able to ambulate in the hallway with crutches indicates that the expected outcome of improved physical mobility due to the fractured leg has been met. This demonstrates progress towards independence and recovery. A is incorrect because the patient still requires assistance, indicating dependency. C is incorrect because denial of pain does not necessarily indicate improved physical mobility. D is incorrect because it is too general and does not directly show achievement of the specific goal related to physical mobility.

Correct Answer: A

Rationale: Step 1: Evaluation phase assesses if client outcomes have been achieved. Step 2: Determines effectiveness of nursing interventions. Step 3: Validates if goals are met or adjustments are needed. Step 4: Reflects on the success of the care plan. Step 5: Choice A is correct as it directly relates to evaluating the effectiveness of nursing care. Summary: - Choice B is incorrect as revising health history is part of assessment. - Choice C is incorrect as establishing priorities is part of the planning phase. - Choice D is incorrect as formulating new nursing diagnoses is part of the diagnosis phase.

Correct Answer: C

Rationale: Rationale for correct answer C: In Hashimoto's thyroiditis, an autoimmune disorder causing hypothyroidism, we expect to see normal to elevated TSH levels due to the pituitary gland stimulating the thyroid to produce more hormones. T4 and T3 levels may be within normal range or slightly decreased. Choice C reflects this pattern with T4 at 22 ug/dl, T3 at 200 ng/dl, and TSH at 0.1 uIU/ml. Summary of why other choices are incorrect: - Choice A: T4 and T3 levels are higher than expected in Hashimoto's thyroiditis, and TSH should be elevated, not stated as normal. - Choice B: An undetectable TSH level is typically seen in hyperthyroidism, not hypothyroidism like Hashimoto's. - Choice D: T4 and T3 levels are significantly lower than expected, and TSH is much higher than typically seen in Hashimoto's

Correct Answer: D

Rationale: The correct answer is D: Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Thrombocytopenia is a low platelet count, which can lead to impaired blood clotting and potential bleeding. Ineffective tissue perfusion is the most critical concern as it can lead to life-threatening complications like hemorrhage. Activity intolerance, impaired tissue integrity, and impaired oral mucous membranes are important but do not pose an immediate threat to the client's life compared to the risk of hemorrhage from thrombocytopenia.