Fundamentals Nursing Process Questions

Correct Answer: B

Rationale: The correct answer is B because ordinal petition in the family is not a recognized risk factor for developing cancer. Age is a well-known risk factor as cancer incidence increases with age. Race can also influence cancer risk due to genetic and environmental factors. Lifestyle choices such as smoking, diet, and physical activity can significantly impact the likelihood of developing cancer. In contrast, ordinal petition in the family does not have a direct association with cancer risk.

Correct Answer: C

Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale (GCS) assesses the level of consciousness by evaluating these three factors. Eye opening assesses the patient's ability to open their eyes spontaneously or in response to stimuli. Verbal response evaluates the patient's ability to speak or respond to verbal stimuli. Motor response assesses the patient's motor function by testing responses to commands or painful stimuli. Choice A is incorrect because it includes "response to pain" instead of "verbal response." Choice B is incorrect because it includes "verbal response" instead of "eye opening." Choice D is incorrect because it includes "eye opening" instead of "verbal response." In summary, the GCS evaluates eye opening, verbal response, and motor response to determine the level of consciousness in patients.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. This is the priority intervention because a high temperature and diaphoresis indicate potential respiratory distress. Oxygen therapy can help improve oxygenation and support respiratory function. Providing frequent linen changes (B) is important for hygiene but not the priority. Fluid intake (C) is essential but not as urgent as addressing respiratory distress. Maintaining complete bed rest (D) may be necessary but addressing oxygenation takes precedence in this case.

Correct Answer: A

Rationale: The correct answer is A because continuous assessment allows for timely identification of changes in the client's condition. This is crucial for providing appropriate and timely interventions. Assessing the client only at specific times (choices B and C) may lead to missing important changes. Choice D is incorrect because assessments should not be limited to physician rounds; they should be ongoing to ensure comprehensive care.

Correct Answer: B

Rationale: The correct answer is B: A hypothermia blanket. This is important because hypothermia can lead to complications such as shivering, increased risk of infection, and altered drug metabolism. Checking for the hypothermia blanket ensures Mrs. Zeno's temperature is regulated, promoting safety. A: A tracheostomy set is not directly related to Mrs. Zeno's immediate safety unless she has a tracheostomy in place. C: An intravenous set-up is important for administering medications, fluids, or blood products, but it is not directly related to Mrs. Zeno's safety at the bedside. D: A syringe and edrophonium HCl(Tensilon) is specific to a diagnostic test for myasthenia gravis, which may not be relevant to Mrs. Zeno's current condition or safety.