Nursing Process Test Bank

Correct Answer: C

Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice D) is not as reliable as urinary output for assessing fluid status.

Correct Answer: C

Rationale: The correct answer is C: Urinary output every hour. This is because assessing urinary output is crucial for monitoring fluid balance in burn patients. Adequate urine output indicates proper fluid replacement, while decreased output may indicate dehydration. Recording weights daily (choice A) may be important but not as immediate and specific as urinary output. Blood pressure every 15 minutes (choice B) is too frequent and not directly related to fluid replacement in this context. Monitoring peripheral edema every 4 hours (choice D) is not as reliable as urinary output for assessing fluid status.

Correct Answer: C

Rationale: The correct nursing diagnosis is C: Deficient fluid volume. The patient's symptoms indicate dehydration, as evidenced by tachycardia, increased thirst, decreased urine output, and increased body temperature. This points to a lack of fluid in the body. Option A, adult failure to thrive, does not address the immediate issue of fluid volume. Option B, hypothermia, is incorrect as the patient has an increased body temperature. Option D, nausea, is not a primary issue compared to the symptoms indicating dehydration. Therefore, the correct nursing diagnosis is C: Deficient fluid volume.

Correct Answer: C

Rationale: Step 1: Identify the correct answer - C: �I feel dizzy, I�ll skip my dose for a few days.� Step 2: Explanation - This statement indicates that the client is experiencing a known side effect of prazosin (dizziness) and plans to stop the medication temporarily without consulting the healthcare provider, showing noncompliance. Step 3: Supporting details - Skipping doses can lead to ineffective treatment and potential health risks. Step 4: Comparison with other choices: A: This statement shows the client questioning the need for medication but does not indicate current noncompliance. B: This statement demonstrates difficulty reading labels but does not directly relate to medication compliance. D: This statement shows awareness about medication interactions but does not indicate noncompliance with the prescribed medication regimen. Summary: Choice C is correct as it directly reflects noncompliance by planning to skip doses without consulting the healthcare provider, leading to potential adverse outcomes. Choices A, B, and D do not demonstrate the

Correct Answer: B

Rationale: The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications. A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances. C: Hyperchloremia is not a common concern in this scenario based on the given lab values. D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.