Nursing Process Practice Questions Quizlet

Correct Answer: B

Rationale: The correct answer is B. Polymyositis can affect muscles involved in swallowing, leading to aspiration risk. Therefore, it's crucial for the client to exhibit no signs or symptoms of aspiration. Choice A is unrelated to polymyositis. Choice C involves issues with muscle weakness rather than aspiration risk. Choice D relates to cognitive function, not a common issue with polymyositis.

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: B

Rationale: The correct answer is B: Clonidine (Catapres). Clonidine is known to cause headache as a side effect due to its mechanism of action affecting blood pressure regulation in the brain. Furosemide (A) is a diuretic that typically causes electrolyte imbalances, not headaches. Atenolol (C) is a beta-blocker used for hypertension, which can cause fatigue but not typically headaches. Adalat (D) is a calcium channel blocker that usually causes peripheral edema, not headaches.

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: C

Rationale: The correct answer is C. Aling Maria is admitted for myxedema, which is severe hypothyroidism. Symptoms of hypothyroidism include lethargy, weight gain, slow speech, and decreased respiratory rate. Bradycardia, weight loss, heart failure, and diarrhea are not typical symptoms of myxedema. Tachycardia, constipation, and exopthalmus are more commonly associated with hyperthyroidism. Hypothermia, weight loss, and increased respiratory rate are not consistent with myxedema. Thus, choice C is the most appropriate initial assessment for Aling Maria.