Fundamentals of Nursing Nursing Process Questions

Correct Answer: B

Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease. Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI). Step 3: Age is a risk factor for CAD but not directly linked to MI development. Step 4: Medication usage may impact risk factors but is not a direct cause of MI. Step 5: Gender can influence risk but is not the primary factor in MI development.

Correct Answer: C

Rationale: The correct answer is C: To rule out cholinergic crisis Neostigmine. Edrophonium HCL is a short-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis, as both conditions present similarly with muscle weakness. Administering edrophonium HCL will help determine if the patient's worsening weakness is due to excessive cholinergic stimulation from neostigmine (cholinergic crisis) or inadequate acetylcholine at the neuromuscular junction (myasthenic crisis). This step is crucial for proper management, as treating cholinergic crisis with more cholinesterase inhibitors like neostigmine can worsen symptoms. Incorrect choices: A: For its synergistic effect - Edrophonium HCL does not have a synergistic effect with neostigmine. B: Because of the client's resistance to - Resistance to neostigmine is not a reason to administer edrophonium H

Correct Answer: D

Rationale: The correct answer is D: Stop the transfusion. This is the first action the nurse should take because the sudden fever could indicate a transfusion reaction. Stopping the transfusion is crucial to prevent further complications. Continuing to monitor vital signs (choice C) may delay necessary intervention. Forcing fluids (choice A) could worsen the situation if it is a reaction to the transfusion. Increasing the flow rate of IV fluids (choice B) is not indicated as the priority is to stop the transfusion to prevent a potential adverse event.

Correct Answer: A

Rationale: The correct answer is A: Human Needs (Maslow) model. The nurse is using a systematic approach based on Maslow's Hierarchy of Needs, which includes physiological, safety, love/belonging, esteem, and self-actualization needs. This model organizes assessment data by prioritizing these universal life requirements. Incorrect choices: B: Functional Health Patterns model - This model focuses on 11 functional health patterns, not the hierarchy of universal life requirements. C: Human Response Patterns model - This model focuses on the individual's response to stressors, not prioritizing universal life requirements. D: Body System model - This model focuses on assessing specific body systems, not the holistic approach of addressing all life requirements.

Correct Answer: A

Rationale: The correct answer is A: "Disturbed thought processes." This is the problem statement because it identifies the client's main issue, which is the disturbance in their thought processes. The "related to" part (B) indicates the cause, "Alzheimer's disease" (C) is the etiology, and "incoherent language" (D) is the evidence. By focusing on the problem statement, the nurse can develop appropriate interventions to address the client's disturbed thought processes.