Nursing Process Quizlet Questions

Correct Answer: D

Rationale: The correct answer is D: Preventing bone injury. In multiple myeloma, bone lesions are common due to bone destruction by abnormal plasma cells. Preventing bone injury is crucial to avoid fractures and bone pain. This can be achieved through careful handling, fall prevention, and avoiding activities that may increase the risk of bone damage. Monitoring respiratory status (A) is not the priority in multiple myeloma. Balancing rest and activity (B) is important but not as critical as preventing bone injury. Restricting fluid intake (C) is not typically necessary unless there are specific indications like renal issues.

Correct Answer: C

Rationale: The correct answer is C: Neck vein distention. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia, causing fluid overload. This can manifest as neck vein distention due to increased venous pressure. Tetanic contractions (A) and weight loss (B) are not typical complications of SIADH; tetany is more associated with hypocalcemia and weight loss is not a common manifestation. Polyuria (D) is actually the opposite of what is seen in SIADH, which is characterized by water retention and concentrated urine.

Correct Answer: B

Rationale: The correct answer is B because providing frequent mouth care to Mr. Franco is important to remove dried blood when the tongue is bitten during a seizure. This is crucial for preventing infection and promoting oral hygiene. Choices A, C, and D are incorrect because the primary reason for mouth care in this case is to address the physical consequences of a seizure, such as tongue biting and potential injury, rather than thirst, tactile stimulation, or prevention of oral mucosal issues related to mouth breathing in a comatose patient.

Correct Answer: C

Rationale: The correct answer is C because it clearly states a measurable outcome by specifying that the client will be able to list five symptoms of infection. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). Choice A lacks specificity and measurability. Choice B is vague and does not provide a quantifiable measure of success. Choice D does not specify who will be observing the symptoms or how they will be documented. Overall, choice C stands out as the most appropriate outcome as it is clear, achievable, and directly related to assessing the client's understanding of infection symptoms.

Correct Answer: B

Rationale: Step 1: Activity intolerance is defined as insufficient physiological or psychological energy to endure or complete required or desired daily activities. Step 2: In the scenario, the patient experiences shortness of breath when getting out of bed, indicating decreased ability to tolerate physical activity. Step 3: This shortness of breath is a defining characteristic of activity intolerance as it reflects the patient's limited ability to perform activities of daily living. Step 4: Other symptoms like decreased oral intake, decreased oxygen saturation, and productive cough may be related to other health issues but are not specific to activity intolerance. Step 5: Therefore, choice B is the correct answer as it includes a key defining characteristic of activity intolerance, while other choices do not directly relate to the concept.