Fundamentals Nursing Process Questions

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: 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: B

Rationale: The correct answer is B: Pathologic bone fractures. In multiple myeloma, there is an increase in osteoclast activity leading to bone destruction, making patients prone to pathologic fractures. Chronic liver failure (A), acute heart failure (C), and hypoxemia (D) are not directly associated with multiple myeloma pathophysiology. This highlights the importance of understanding the disease process to determine the correct answer.

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.

Correct Answer: A

Rationale: The correct answer is A: Below 70mg/dl. Hypoglycemia is defined as a blood glucose level below 70mg/dl. Symptoms of hypoglycemia include confusion, shakiness, and sweating. Treating hypoglycemia involves administering fast-acting carbohydrates. Choices B, C, and D are incorrect because they describe blood glucose levels that are within the normal or hyperglycemic range, which are not indicative of hypoglycemia. It is essential for the nurse to recognize and promptly address hypoglycemia to prevent serious complications.