Nursing Process Quizlet Questions

Nursing Process Quizlet Questions Related

Review Nursing Process Quizlet Questions related questions and content

. A client is admitted to the health care facility for evaluation for Addison’s disease. Which laboratory test result best supports a diagnosis of Addison’s disease?

  • A. Blood urea nitrogen (BUN) level of
  • B. Serum sodium level of 134 mEq/L
  • C. Serum potassium level of 5.8 mEq/L
  • D. Blood glucose level of 90 mg/dl
Correct Answer: C

Rationale: Step-by-step rationale for choice C (Serum potassium level of 5.8 mEq/L) being the best to support a diagnosis of Addison's disease:
1. Addison's disease is characterized by adrenal insufficiency, leading to decreased aldosterone secretion.
2. Decreased aldosterone causes hyperkalemia due to impaired potassium excretion.
3. Elevated serum potassium levels above the normal range (3.5-5.0 mEq/L) are a classic finding in Addison's disease.
4. Therefore, a serum potassium level of 5.8 mEq/L strongly supports the diagnosis of Addison's disease.

Summary:
- Choice A (BUN level): BUN is not specific to Addison's disease and does not directly relate to adrenal function.
- Choice B (Serum sodium level): Hyponatremia is a common finding in Addison's disease, but it is not as specific as hyperkalemia.
- Choice D (Blood glucose level): Blood glucose

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A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?

  • A. Cool, clammy skin
  • B. Increased urine osmolarity
  • C. Distended neck veins
  • D. serum sodium level
Correct Answer: B

Rationale: The correct answer is B: Increased urine osmolarity. In hyperglycemia, the body tries to eliminate excess glucose through increased urine output, causing a concentrated urine with high osmolarity. This indicates fluid deficit. Cool, clammy skin (A) may suggest poor perfusion but not fluid volume deficit. Distended neck veins (C) are more indicative of fluid overload. Serum sodium level (D) may be elevated in fluid deficit but does not directly assess volume status like urine osmolarity does.

While planning for proportionate distribution of restricted fluid volumes, what is the reason for a nurse to ensure that the client is actively involved during the development of the plan?

  • A. It promotes the clients compliance with therapy
  • B. It minimizes the chances of adverse effects
  • C. It promotes a strict food and fluid intake habit
  • D. It raises the self esteem of the client
Correct Answer: A

Rationale: Step 1: Involving the client in planning increases their understanding and ownership of the plan.
Step 2: Understanding leads to better compliance with therapy recommendations.
Step 3: Compliance improves outcomes and prevents complications.
Step 4: Thus, choice A is correct. Choices B, C, and D lack direct links to client involvement in planning and compliance.

Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;

  • A. Provide positive feedback when he uses the word correctly
  • B. Wait for him to verbally state needs regardless of how long it may take
  • C. Suggest that he get help at home because the disability is permanent
  • D. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication Situation - Patricia Zeno is a client with history myasthenia gravis
Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct:
1. Positive reinforcement helps enhance communication skills in individuals with expressive aphasia.
2. Providing positive feedback when Mr. Reyea uses words correctly encourages him to continue trying to communicate.
3. It boosts his confidence and motivation, leading to improved verbal communication over time.

Summary of why other choices are incorrect:
B. Waiting indefinitely for Mr. Reyea to verbally state his needs may lead to frustration and hinder effective communication.
C. Suggesting permanent help at home assumes Mr. Reyea's condition cannot improve, which is not necessarily true for expressive aphasia.
D. Helping the family accept Mr. Reyea's communication challenges does not actively support his communication improvement and may limit his progress.

A nurse is working with a dying client and his family. Which communication technique is most important to use?

  • A. Reflection
  • B. Clarification
  • C. Interpretation
  • D. Active listening
Correct Answer: D

Rationale: The correct answer is D: Active listening. Active listening involves fully concentrating, understanding, responding, and remembering what is being said. In end-of-life care, it is crucial to provide emotional support and create a safe space for clients and their families to express their thoughts and feelings. Active listening helps the nurse to establish trust, show empathy, and validate the emotions of the clients and their families. Reflection (A), Clarification (B), and Interpretation (C) may be beneficial in certain situations, but in end-of-life care, active listening plays a pivotal role in fostering meaningful and supportive communication.

The nurse is preparing to administer a unit of blood to a client’s who’s anemic. After its removal from the refrigerator, the blood should be administered within:

  • A. 1 hour
  • B. 4 hours
  • C. 2 hours
  • D. 6 hours
Correct Answer: C

Rationale: The correct answer is C: 2 hours. Blood should be administered within 30 minutes to 4 hours after removal from the refrigerator to prevent bacterial growth and maintain its efficacy. Option C falls within this timeframe, ensuring safety and effectiveness. Option A (1 hour) is too short, while option B (4 hours) and option D (6 hours) exceed the recommended timeframe, increasing the risk of bacterial contamination and compromising the quality of the blood product.

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