Nursing Process Practice Questions Quizlet

Correct Answer: A

Rationale: The correct answer is A: Assessment. In the scenario, the nurse failed to assess the patient's condition promptly after the patient complained of feeling dizzy and light-headed. Assessment is the first phase of the nursing process and involves collecting data to identify the patient's health status. By not reassessing the patient's vital signs and symptoms, the nurse missed an opportunity to detect the worsening condition. The other choices are incorrect because the error occurred before diagnosis (B), implementation (C), and evaluation (D) phases. In diagnosis, the nurse identifies the patient's problems; in implementation, the nurse carries out the care plan; and in evaluation, the nurse assesses the effectiveness of interventions.

Correct Answer: A

Rationale: The correct answer is A: Assessment. The nurse made an error in the assessment phase by not communicating the patient's condition promptly. Assessment involves collecting data and recognizing changes in the patient's condition. By not informing the nurse about feeling dizzy and light-headed, the nurse missed crucial information that could have indicated a deteriorating condition. The other choices are incorrect because: B: Diagnosis comes after assessment and involves analyzing data to identify the patient's problems. C: Implementation is the phase where nursing interventions are carried out based on the diagnosis. D: Evaluation is the final phase where the nurse assesses the effectiveness of interventions and outcomes.

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: The correct answer is C: Amount and color of sinus drainage. Assessing the amount and color of sinus drainage is crucial in evaluating the effectiveness of nursing interventions for sinusitis discomfort as it indicates the presence of infection or inflammation. Changes in color or amount can signify improvement or worsening of the condition. WBC count (A) may indicate infection but doesn't directly reflect sinusitis discomfort. Capillary refill (B) assesses circulation, not sinusitis. Comfort level (D) is subjective and can vary among individuals, making it less reliable for assessing the effectiveness of interventions.

Correct Answer: C

Rationale: The correct answer is C because antihistamines can suppress the immune response that the skin test is designed to detect, leading to false negative results. By inhibiting the body's allergic response, antihistamines can mask the presence of an allergy, giving the false impression that the individual is not allergic to a particular substance. This can lead to misdiagnosis and improper treatment. Choices A, B, and D are incorrect because antihistamines do not affect bleeding, aggravate allergic reactions, or cause wheezing in the context of a skin test.