The nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for:

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: C

Rationale: The correct answer is C: 0.90% sodium chloride. When administering a hypotonic solution like 0.45% sodium chloride or 5% dextrose in water, water moves into the cells causing them to swell. This can exacerbate symptoms of hypovolemia such as low blood pressure and decreased perfusion. However, 0.90% sodium chloride is an isotonic solution and will not further exacerbate hypovolemic symptoms. Choices A, B, and D are hypotonic solutions that can worsen hypovolemic symptoms by causing cellular swelling.

Correct Answer: B

Rationale: Step-by-step rationale: 1. In a Romberg test, the patient stands with feet together and eyes closed to assess proprioception. 2. Swaying, losing balance, or arm drifting indicates impaired proprioception, suggesting a positive Romberg sign, which is abnormal. 3. Hypotension (choice A) is not directly related to the Romberg test. 4. Sneezing and wheezing (choice C) are unrelated to the test. 5. Excessive cerumen in the outer ear (choice D) does not affect proprioception. Summary: Choice B is correct as it directly relates to impaired proprioception, which is abnormal in a Romberg test. Choices A, C, and D are incorrect as they are unrelated to the purpose of the test.

Correct Answer: B

Rationale: The correct answer is B: Sit upright, leaning slightly forward. This position helps to minimize blood flow to the head, reducing the risk of increased bleeding. It also prevents blood from flowing down the throat, reducing the risk of aspiration. A: Lying supine with the neck extended can increase pressure on the blood vessels in the head, potentially worsening the epistaxis. C: Blowing the nose and putting lateral pressure can disrupt any clots that may have formed and increase bleeding. D: Holding the nose while bending forward at the waist can lead to blood flowing down the throat and increase the risk of aspiration.

Correct Answer: B

Rationale: Rationale: B is correct because cystoclisis is the process of maintaining patency of a foley catheter by irrigating it with a sterile solution. This prevents blockages and promotes proper drainage. A, C, and D are incorrect because cystoclisis is not related to increasing bladder atony, removing blood clots, or altering urine specific gravity.

Correct Answer: D

Rationale: Step 1: The DASH diet is specifically designed to help lower blood pressure, making it the most appropriate choice for clients with hypertension. Step 2: The DASH diet emphasizes fruits, vegetables, whole grains, lean proteins, and low-fat dairy, all of which are beneficial for managing hypertension. Step 3: The diet also limits sodium intake, which is crucial for controlling blood pressure. Step 4: The other options (A, B, and C) do not have the same evidence-based focus on hypertension management and may not be as effective in lowering blood pressure.

Correct Answer: C

Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.

Correct Answer: B

Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying potential complications that may arise due to the client's health issue. This is important for developing effective interventions to prevent or manage these complications. Choice A focuses on the client's problem itself, not on potential complications. Choice C is related to nursing diagnosis, not collaborative problems. Choice D refers to medical diagnosis, which is different from collaborative problems involving nursing and other healthcare disciplines. Therefore, B is the correct focus for a diagnostic statement in a collaborative problem scenario.

Correct Answer: D

Rationale: The correct answer is D, decreased body temperature and cold intolerance, because these are classic signs of hypothyroidism due to decreased thyroid hormone levels. The body's metabolism slows down, leading to a lower core body temperature and reduced ability to tolerate cold. Exophthalmos and conjunctival redness (choice A) are associated with hyperthyroidism. Flushed, warm, moist skin (choice B) is indicative of hyperthyroidism as well, due to increased metabolic rate. A systolic murmur at the left sternal border (choice C) is not a common finding in hypothyroidism.