Fundamentals Nursing Process Questions

Correct Answer: B

Rationale: The correct answer is B: L4-L5. This is because the L4-L5 intervertebral disc segment experiences the highest amount of mechanical stress and mobility in the lumbar spine, making it more prone to herniation. Additionally, nerve roots at this level innervate the lower extremities, making it a common site for symptoms such as sciatica. Choices A, C, and D are incorrect because herniations at those levels are less common due to lower mechanical stress and mobility compared to L4-L5.

Correct Answer: B

Rationale: Step-by-step rationale: 1. In a Romberg test, the patient stands with feet together and eyes closed to assess proprioception. 2. Swaying, losing balance, or arm drifting indicates impaired proprioception, suggesting a positive Romberg sign, which is abnormal. 3. Hypotension (choice A) is not directly related to the Romberg test. 4. Sneezing and wheezing (choice C) are unrelated to the test. 5. Excessive cerumen in the outer ear (choice D) does not affect proprioception. Summary: Choice B is correct as it directly relates to impaired proprioception, which is abnormal in a Romberg test. Choices A, C, and D are incorrect as they are unrelated to the purpose of the test.

Correct Answer: A

Rationale: The correct answer is A: Muscle rigidity and spasms. Ketamine can cause muscle rigidity and spasms as a side effect. The anesthesiologist should monitor the client for this adverse reaction. Muscle rigidity and spasms are common with ketamine administration and can affect the client's comfort and safety during the procedure. It is important for the nurse to promptly address any signs of muscle rigidity or spasms to prevent complications. Summary of why other choices are incorrect: B: Hiccups - Ketamine can cause hiccups, but it is not the primary side effect to monitor for in this scenario. C: Extrapyramidal reactions - Ketamine does not typically cause extrapyramidal reactions. D: Respiratory depression - Ketamine is known for its minimal effect on respiratory depression compared to other anesthetics. Monitoring respiratory depression is still important, but not the primary concern with ketamine administration in this case.

Correct Answer: B

Rationale: The correct answer is B: Thymectomy. Thymectomy involves the surgical removal of the thymus gland, which is often abnormal in individuals with myasthenia gravis. The thymus plays a role in the development of the immune system and can contribute to the autoimmune response seen in myasthenia gravis. By removing the thymus gland, the autoimmune response may be reduced, leading to substantial remission of symptoms. Choice A, Esophagostomy, involves creating a surgical opening into the esophagus and is not a treatment for myasthenia gravis. Choice C, Myomectomy, is the surgical removal of uterine fibroids and is unrelated to myasthenia gravis. Choice D, Spleenectomy, is the removal of the spleen and is not a standard treatment for myasthenia gravis.

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.