The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN

Correct Answer: A

Rationale: The correct answer is A: Assessment. In this scenario, the nurse failed to assess the patient's condition promptly after being informed of feeling dizzy and light-headed. Assessment involves collecting data to identify actual or potential health problems. By not promptly assessing the patient's worsening condition, the nurse missed an essential step in the nursing process. Choice B: Diagnosis comes after assessment and involves identifying the patient's health problems based on collected data. Choice C: Implementation is the phase where the nurse carries out the plan of care. Choice D: Evaluation occurs after implementation to determine if the interventions were effective.

Correct Answer: D

Rationale: The correct answer is D: Involve the son in the plan of care as much as possible. This is important for several reasons. Firstly, involving the son promotes family-centered care, which can improve patient outcomes. Secondly, the son may provide valuable insights into the patient's preferences and needs. Thirdly, it can help reduce the patient's confusion by providing familiar support. Option A is incorrect as it disregards the potential benefits of involving family members. Option B is incorrect as it focuses on the patient's rest without considering the emotional support the son may provide. Option C is incorrect as it assumes the gender of the family member matters more than their relationship to the patient.

Correct Answer: D

Rationale: The correct answer is D: Pathological fractures. In multiple myeloma, abnormal plasma cells can weaken the bones, leading to fractures even with minimal trauma. The nurse should monitor for signs of bone pain, decreased mobility, and pathological fractures to prevent complications. Uncontrolled bleeding (A) is not typically associated with multiple myeloma. Liver engorgement (B) is more commonly seen in conditions like congestive heart failure or liver disease. Respiratory distress (C) is not a common manifestation of multiple myeloma. Therefore, the nurse should focus on monitoring for pathological fractures as a priority in a patient with multiple myeloma.

Correct Answer: B

Rationale: The correct answer is B. Mr. Sy's statement indicates he understands the pre-operative fasting instructions, which is crucial to prevent aspiration during surgery. Not eating after midnight reduces the risk of complications. A: Incorrect. Wearing a pneumatic compression device post-surgery is important, but this statement does not demonstrate understanding of pre-surgery preparations. C: Incorrect. Knowing the skin preparation site size does not indicate understanding of the surgery process. D: Incorrect. Signing the consent form at the operating table may indicate lack of understanding of the consent process and timing. In summary, choice B is correct as it shows Mr. Sy's awareness of the fasting requirement before surgery, which is crucial for a safe operation.

Correct Answer: B

Rationale: The correct answer is B because the patient being able to ambulate in the hallway with crutches indicates that the expected outcome of improved physical mobility due to the fractured leg has been met. This demonstrates progress towards independence and recovery. A is incorrect because the patient still requires assistance, indicating dependency. C is incorrect because denial of pain does not necessarily indicate improved physical mobility. D is incorrect because it is too general and does not directly show achievement of the specific goal related to physical mobility.

Correct Answer: C

Rationale: The correct answer is C: Paroxysms or shortness of breath. Asthma is characterized by episodes of wheezing, coughing, chest tightness, and shortness of breath, known as paroxysms. This symptom is caused by inflammation and constriction of the airways in response to triggers such as allergens or irritants. A: Production of abnormally thick, sticky mucus in lungs is more indicative of conditions like cystic fibrosis, not asthma. B: Faulty transport of sodium in lung cells is associated with conditions like cystic fibrosis, not asthma. D: Altered electrolyte balance in the sweat glands is a symptom of cystic fibrosis, not asthma. In summary, paroxysms or shortness of breath is a key sign of asthma due to airway inflammation and constriction, distinguishing it from the other choices that are more indicative of cystic fibrosis.

Correct Answer: C

Rationale: The correct answer is C: Amount and color of sinus drainage. Assessing the amount and color of sinus drainage is crucial in evaluating the effectiveness of nursing interventions for sinusitis discomfort as it indicates the presence of infection or inflammation. Changes in color or amount can signify improvement or worsening of the condition. WBC count (A) may indicate infection but doesn't directly reflect sinusitis discomfort. Capillary refill (B) assesses circulation, not sinusitis. Comfort level (D) is subjective and can vary among individuals, making it less reliable for assessing the effectiveness of interventions.

Correct Answer: D

Rationale: The correct answer is D: Stapedectomy. This procedure is used to correct otosclerosis by removing the stapes bone and replacing it with a prosthetic device. This restores normal hearing by allowing sound waves to travel through the ear properly. Myringotomy (A) is a procedure to drain fluid from the middle ear, not to correct otosclerosis. Mastoidectomy (B) is the removal of infected mastoid air cells, not related to otosclerosis. Myringoplasty (C) is a surgical procedure to repair a perforated eardrum, not used for otosclerosis. Stapedectomy is the most appropriate choice for correcting otosclerosis as it directly addresses the abnormal bone growth in the middle ear.

Correct Answer: A

Rationale: The correct answer is A: Assessment. In this scenario, the nurse failed to assess the patient's condition promptly after being informed of feeling dizzy and light-headed. Assessment involves collecting data to identify actual or potential health problems. By not promptly assessing the patient's worsening condition, the nurse missed an essential step in the nursing process. Choice B: Diagnosis comes after assessment and involves identifying the patient's health problems based on collected data. Choice C: Implementation is the phase where the nurse carries out the plan of care. Choice D: Evaluation occurs after implementation to determine if the interventions were effective.