Fundamentals Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate neurological, musculoskeletal, or sensory issues affecting mobility. Speech (B) is related to communication, judgment (C) to decision-making, and endurance (D) to stamina, not specifically to loss of ability. Balance is crucial for mobility and overall function, making it a priority area for assessment in healthcare settings.

Correct Answer: C

Rationale: The correct answer is C: The patient is apprehensive about discharge. This is the correct answer because the patient's fear of going home and being alone indicates apprehension about discharge, which is a common feeling among patients transitioning from the hospital to home care. This subjective data suggests that the patient may need additional support and education prior to discharge to address their fears and concerns. A: The patient can now perform the dressing changes without help - This is incorrect because the patient's fear of going home and being alone does not necessarily indicate their ability to perform dressing changes independently. B: The patient can begin retaking all of the previous medications - This is incorrect as the fear expressed by the patient is related to being alone at home, not to medication management. D: The patient�s surgery was not successful - This is incorrect as there is no indication in the subjective data provided that the surgery was not successful.

Correct Answer: B

Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying potential complications that may arise due to the client's health issue. This is important for developing effective interventions to prevent or manage these complications. Choice A focuses on the client's problem itself, not on potential complications. Choice C is related to nursing diagnosis, not collaborative problems. Choice D refers to medical diagnosis, which is different from collaborative problems involving nursing and other healthcare disciplines. Therefore, B is the correct focus for a diagnostic statement in a collaborative problem scenario.

Correct Answer: C

Rationale: The correct answer is C: 0.90% sodium chloride. When administering a hypotonic solution like 0.45% sodium chloride or 5% dextrose in water, water moves into the cells causing them to swell. This can exacerbate symptoms of hypovolemia such as low blood pressure and decreased perfusion. However, 0.90% sodium chloride is an isotonic solution and will not further exacerbate hypovolemic symptoms. Choices A, B, and D are hypotonic solutions that can worsen hypovolemic symptoms by causing cellular swelling.

Correct Answer: D

Rationale: The correct answer is D: pain in the scapular region. This is because a herniated nucleus pulposus at the C4-C5 and C5-C6 interspaces typically results in pain radiating from the neck to the scapular region due to nerve compression at those levels. The other choices are incorrect as constant, throbbing headaches are not typically associated with this specific diagnosis, clonus in the lower extremities is more indicative of lower spinal cord involvement, and numbness of the face is not a common symptom of herniated discs at these levels.