Fundamentals Nursing Process Questions

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Blood and fluid loss from frequent diarrhea may cause hypovolemia and you can quickly assess volume depletion in Miss CC by:

  • A. Measuring the quantity and specific gravity of her urine output
  • B. Taking her blood pressure
  • C. Comparing the patient’s present weight with her last weight
  • D. Administering the oral water test
Correct Answer: C

Rationale: The correct answer is C: Comparing the patient’s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia.

Explanation of why other choices are incorrect:
A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes.
B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea.
D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.

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Arthur, a 66-year old client for pneumonia has a temperature ranging from 39° to 40° C with periods of diaphoresis. Which of the following interventions by Nurse Carlos would be a priority?

  • A. Administer oxygen therapy
  • B. provide frequent linen changes
  • C. provide fluid intake 3L/day
  • D. maintain complete bed rest
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.

The nurse will assess a loss of ability in which of the following areas?

  • A. Balance
  • B. Speech
  • C. Judgment
  • D. Endurance
Correct Answer: A

Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate neurological, musculoskeletal, or sensory issues affecting mobility. Speech (B) is related to communication, judgment (C) to decision-making, and endurance (D) to stamina, not specifically to loss of ability. Balance is crucial for mobility and overall function, making it a priority area for assessment in healthcare settings.

The neurologist tests the 4th and 6th cranial nerves together by having a patient do which of the following?

  • A. Turn his head to the right and left
  • B. Say “ahhh”
  • C. Identify whispering in his ears
  • D. Follow his finger with his eyes
Correct Answer: D

Rationale: The correct answer is D because testing the 4th (trochlear) and 6th (abducens) cranial nerves involves assessing eye movements. The trochlear nerve controls downward and inward eye movement, while the abducens nerve controls lateral eye movement. Asking the patient to follow the finger with their eyes tests the function of both nerves simultaneously. Choices A, B, and C do not specifically target the 4th and 6th cranial nerves, making them incorrect options.

Mrs. Go a 75-year old female suffered a fdall and is diagnosed with a herniated nucleus pulposus at the C4-C5 interspace, and a second st the C5-C6 interspace.Which of the following findings would the nurse expect to discover during the assessment?

  • A. constant, throbbing headaches
  • B. clonus in the lower extremities
  • C. Numbness of the face
  • D. pain in the scapular region
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.

The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:

  • A. insulin.
  • B. poatassium chloride.
  • C. furosemide (Lasix)
  • D. vasopressin (Pitressin).
Correct Answer: D

Rationale: The correct answer is D: vasopressin (Pitressin). In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), which leads to excessive urination and thirst. Vasopressin is a synthetic form of ADH that helps regulate water balance by reducing urine output. Therefore, administering vasopressin would help manage the symptoms of diabetes insipidus. Insulin (A) is used for diabetes mellitus, not diabetes insipidus. Potassium chloride (B) is used to correct potassium imbalances, not specific to diabetes insipidus. Furosemide (Lasix) (C) is a diuretic that increases urine output, which would worsen the symptoms of diabetes insipidus.

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