foundations of nursing test bank

Correct Answer: A

Rationale: Correct Answer: A. Provide empathy and encouragement in an effort to foster a positive outlook. Rationale: 1. Empathy and encouragement are essential in establishing rapport and trust with the patient. 2. By fostering a positive outlook, the nurse can help alleviate the patient's anxiety and fears. 3. Encouraging a positive mindset can improve the patient's adherence to treatment. 4. It is important to address the patient's concerns and provide support rather than dismissing them. Summary: B: Telling the patient it is his decision may not address his emotional needs and could lead to further distress. C: Reporting the patient's statement to his support system may breach confidentiality and undermine trust. D: Referring the patient to social work may be premature without first addressing the patient's emotional concerns directly.

Correct Answer: C

Rationale: The correct answer is C because folic acid is crucial in preventing neural tube defects and anemia in the developing fetus. The nurse should teach the expectant mother about the importance of taking folic acid supplements before and during pregnancy. Folic acid is essential for proper cell division and growth, reducing the risk of birth defects. Choice A is incorrect because calcium intake is important throughout pregnancy, not just in the first trimester. Choice B is incorrect as protein intake should be adequate to support maternal and fetal growth, not decreased. Choice D is incorrect as excessive intake of vitamins and minerals can be harmful to the mother and the baby. In summary, the expectant mother should be educated on the importance of folic acid supplementation to prevent birth defects and anemia, while also ensuring a balanced diet with all essential nutrients.

Correct Answer: A

Rationale: The correct answer is A: Assessing for mouth droop and decreased lateral eye gaze. After a radical mastoidectomy, the nurse should prioritize assessing for signs of facial nerve damage, such as mouth droop and decreased lateral eye gaze, which can indicate injury to the facial nerve during surgery. This is crucial as immediate intervention may be needed to prevent long-term complications. Choices B, C, and D are incorrect: B: Assessing for increased middle ear pressure and perforated ear drum is not the priority postoperative care for a radical mastoidectomy patient. C: Assessing for gradual onset of conductive hearing loss and nystagmus is not the priority as these are not immediate concerns postoperatively. D: Assessing for scar tissue and cerumen obstructing the auditory canal is not the priority as these are not immediate postoperative complications that require urgent attention.

Correct Answer: C

Rationale: The correct answer is C: Risk for infection related to altered immunologic response. This is the priority nursing diagnosis for a patient preparing for hematopoietic stem cell transplant (HSCT) because the patient's immune system will be severely compromised post-transplant, leading to a high risk of infections. It is crucial to prioritize infection prevention to ensure the patient's safety and well-being. Choice A is incorrect because while fatigue is common in cancer patients, it is not the priority in this case where infection risk is higher. Choice B is incorrect as altered nutrition can be addressed after managing the risk for infection. Choice D is incorrect as body image disturbance is important but not as critical as preventing infections in this highly vulnerable patient population.

Correct Answer: B

Rationale: Interdisciplinary collaboration involves clinicians from different backgrounds integrating their separate plans of care, ensuring a holistic approach to patient care. This fosters a comprehensive understanding of the patient's needs and individualized care. In contrast, multidisciplinary practice involves clinicians working independently without integrating their plans, potentially leading to fragmented care. Choice A is incorrect as interdisciplinary collaboration does have a team leader to coordinate and facilitate communication among team members. Choice C is incorrect because while communication and cooperation are essential in interdisciplinary collaboration, the key distinction is the integration of different perspectives and plans of care. Choice D is incorrect as interdisciplinary collaboration goes beyond just medical expertise and patient preference, involving professionals from various disciplines working together to address all aspects of patient care.