Fundamentals of Nursing Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A: Peripheral neuropathy. Didanosine (ddl) can cause peripheral neuropathy as a side effect, which can exacerbate existing neuropathy. The client's history of peripheral neuropathy warrants caution with this drug to prevent further nerve damage. Incorrect choices: B: Hypertension - Didanosine is not contraindicated in hypertension. C: Diabetes mellitus - While monitoring blood sugar levels is important, didanosine does not directly affect diabetes. D: Asthma - Didanosine does not have a significant impact on asthma. In summary, the client's pre-existing peripheral neuropathy makes it important to exercise caution with didanosine to avoid worsening this condition.

Correct Answer: C

Rationale: The correct answer is C: He walked home in a cold rain. Walking in cold rain can lead to vasoconstriction, which impairs blood flow, increasing the likelihood of a sickle cell crisis in individuals with sickle cell disease. This can cause red blood cells to sickle and block blood vessels, leading to pain and tissue damage. Choices A, B, and D do not directly affect the physiology of sickle cell disease and are less likely to trigger a crisis.

Correct Answer: B

Rationale: The correct answer is B: Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing. This nursing diagnosis takes highest priority for a client with hyperparathyroidism because the client is at risk for skin breakdown due to edema, skin fragility, and poor wound healing caused by the condition. Skin integrity is crucial for preventing infection and promoting overall health. Choice A is incorrect because hyperparathyroidism is not related to thyroid hormone excess, but rather to parathyroid hormone excess. Choice C is incorrect because body image disturbance is not the highest priority compared to the risk of skin breakdown. Choice D is incorrect because hyperparathyroidism typically leads to hypercalcemia and not imbalanced nutrition related to thyroid hormone excess.

Correct Answer: A

Rationale: Correct Answer: A: Cover wound with moist sterile dressing Rationale: 1. Covering the wound with a moist sterile dressing helps maintain a clean and moist environment, promoting wound healing. 2. Moist dressing prevents the wound from drying out and minimizes the risk of infection. 3. The moist environment supports healing by promoting cell growth and preventing tissue damage. 4. It protects the exposed bowel from further injury and contamination. Summary: B: Finding out how this happened is important but not an immediate priority for patient care. C: Placing sterile dry gauze can lead to the wound drying out and hinder healing. D: Pouring sterile water into the wound is not recommended as it can introduce contaminants and is not considered standard care for this situation.

Correct Answer: B

Rationale: The correct answer is B: Potato. Potatoes are high in potassium, which is essential for various bodily functions. Potatoes can help increase potassium intake in patients who require it. Bread, eggs, and cereal are not as rich in potassium as potatoes. Increasing intake of these foods won't provide the necessary boost in potassium levels needed for the patient.