Nursing Process Practice Questions Quizlet

Correct Answer: A

Rationale: Step 1: Level of consciousness is the most reliable index of cerebral state because it directly reflects the functioning of the brain. Changes in consciousness can indicate alterations in cerebral perfusion and potential increases in intracranial pressure. Step 2: Unilateral papillary dilatation may suggest an increase in intracranial pressure, but it is not as reliable as level of consciousness in assessing overall cerebral state. Step 3: Increased systolic blood pressure can occur due to various reasons and may not specifically indicate changes in intracranial pressure. Step 4: Decreased pulse pressure may be related to factors such as hypovolemia or cardiac conditions, but it is not a direct indicator of cerebral state or intracranial pressure.

Correct Answer: C

Rationale: The correct formula to calculate the appropriate morphine dose for the client is 5 mg/kg of body weight. This is the most suitable formula because morphine dosing is typically based on weight to ensure appropriate pain management and to prevent adverse effects. By using this formula, the nurse can calculate the exact dose based on the client's weight, providing personalized care. Choice A (1 mg/kg of body weight) is too low of a dose and may not effectively manage severe pain. Choice B (5 mg/70kg of body weight) is not ideal as it does not account for variations in weight among individuals. Choice D (10mg/70kg of body weight) would result in an overdose for most patients, potentially causing serious harm. Therefore, by using the formula of 5 mg/kg of body weight, the nurse can ensure that the morphine dose is appropriate and safe for the client.

Correct Answer: D

Rationale: The correct answer is D: The patient is able to ambulate 25 feet without pain. This outcome indicates successful plan implementation for impaired mobility due to nerve compression. Ambulating without pain shows improved mobility and nerve compression relief. Choices A, B, and C do not directly address mobility improvement. Choice A focuses on pain level, which is important but not a direct measure of mobility. Choice B refers to upper extremities, not the lower extremities affected by lumbar disk herniation. Choice C addresses medication management, not mobility improvement.

Correct Answer: D

Rationale: Step 1: Hypernatremia is defined by elevated serum sodium levels (>145mEq/L). Step 2: Serum osmolality of 245mOsm/kg is high, consistent with hypernatremia. Step 3: Urine specific gravity below 1.003 indicates dilute urine, a common finding in hypernatremia. Step 4: The combination of elevated serum sodium, high serum osmolality, and low urine specific gravity confirms hypernatremia. Summary: A: Incorrect, as high serum osmolality (not 245mOsm/kg) is associated with hypernatremia. B: Incorrect, as low urine specific gravity (not below 1.003) is seen in hypernatremia. C: Incorrect, as serum sodium needs to be >145mEq/L to indicate hypernatremia.

Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to reflect on the potential causes of their fatigue, leading to a more detailed and insightful response. This open-ended question allows the patient to explore various factors contributing to their fatigue, such as lifestyle habits, medical conditions, or emotional stressors. Choice A focuses on stress, which may not be the primary cause of fatigue for the patient. Choice C is too specific and may not uncover other relevant information. Choice D assumes that sleep duration is the sole factor contributing to fatigue, neglecting other possible causes. Overall, choice B facilitates a more comprehensive discussion and helps the nurse gather valuable information to address the patient's concerns effectively.