Nursing Process Practice Questions Quizlet

Correct Answer: B

Rationale: The correct answer is B, "What reasons do you think are contributing to your fatigue?" This question encourages the patient to explore and express their own thoughts and feelings, leading to a more detailed and comprehensive understanding of the underlying causes of their daytime fatigue. A: "Is there anything that you are stressed about right now that I should know?" - This question is more direct and may not necessarily prompt the patient to delve into the specific reasons for their fatigue. C: "What are your normal work hours?" - While relevant, this question focuses solely on work hours and may not uncover other potential factors contributing to the fatigue. D: "Are you sleeping 8 hours a night?" - While sleep is important, this question is too narrow and may not address other possible reasons for the fatigue.

Correct Answer: D

Rationale: The correct answer is D: Heart. A potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to cardiac arrhythmias and even cardiac arrest. The heart is highly sensitive to potassium levels, as it plays a crucial role in regulating the heart's electrical activity. Elevated potassium levels can disrupt this balance, leading to serious cardiac complications. Summary: A: Lungs - Not directly affected by potassium levels. B: Liver - Not directly affected by potassium levels. C: Kidneys - Kidneys regulate potassium levels but are not the most at risk for dysfunction in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Turn off the antibiotic. This should be the nurse's first action because in an anaphylactic reaction, stopping the administration of the causative agent is crucial to prevent further harm. Continuing the antibiotic (Choice B) can worsen the reaction. Calling the doctor (Choice A) may cause a delay in the immediate intervention needed. Calling for help (Choice C) is important but turning off the antibiotic takes precedence to stop the allergen.

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: 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.