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: Cold sensitivity. Severe anemia leads to decreased oxygen delivery to tissues, causing symptoms like pallor, fatigue, and dyspnea on exertion due to the body compensating for low oxygen levels. Cold sensitivity is not a common symptom associated with anemia. The other choices are directly related to severe anemia due to the lack of oxygen delivery to tissues.

Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is based on the patient's subjective feelings and concerns, which are important to address for a safe discharge. Choices A and B are incorrect as they assume the patient's readiness for independent tasks without considering their emotional state. Choice D is incorrect as there is no objective data provided to support the assumption that the surgery was not successful. It is important for the nurse to acknowledge and address the patient's emotional needs before discharge.

Correct Answer: A

Rationale: The correct answer is A: Trousseau's sign. This involves carpal spasm induced by inflating a blood pressure cuff above systolic pressure, indicating hypocalcemia. The nurse should monitor for this sign in clients at risk for low calcium levels. Hypoglycemia and hypokalemia have specific signs and symptoms not related to Trousseau's sign. Respiratory changes are nonspecific and may not be directly related to monitoring for low calcium levels.

Correct Answer: A

Rationale: The correct answer is A: Active natural immunity. The mother had chickenpox as a child, which triggered her immune system to produce antibodies, providing long-lasting protection. This is an example of active immunity because her immune system actively responded to the pathogen. Summary: B: Passive artificial immunity - This involves receiving pre-made antibodies, not produced by the individual's immune system. C: Passive natural immunity - This is acquired through placental transfer or breastfeeding, not through prior exposure to the pathogen. D: Active artificial immunity - This is acquired through vaccination, not through natural exposure to the pathogen.