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: B

Rationale: The correct answer is B because the nurse should prioritize the patient who has been receiving total parenteral nutrition (TPN) infusing with the same tubing for 26 hours. This patient needs to be seen first to monitor for any potential complications or issues related to TPN administration. Choice A can be ruled out because 50 hours is longer than 26 hours. Choices C and D involve enteral feeding, which is important but generally less critical than TPN. Additionally, choice D has a shorter duration than choice B. Therefore, choice B is the most time-sensitive and critical patient to assess first.

Correct Answer: A

Rationale: The correct answer is A: Charts legibly. This is accurate legally because clear and legible documentation is crucial for accurately conveying patient information, ensuring continuity of care, and meeting legal standards. Illegible handwriting can lead to errors in patient care and legal issues. Choice B is incorrect as labeling a patient as "belligerent" without evidence can be perceived as unprofessional and potentially harmful to the patient. Choice C is incorrect as writing an entry for another nurse can lead to inaccurate documentation and legal consequences. Choice D is incorrect because using correction fluid can raise suspicion of tampering with records and compromise the integrity of the documentation.

Correct Answer: D

Rationale: The correct answer is D, balancing calories. This is because the ChooseMyPlate program emphasizes the importance of maintaining a balance between the calories consumed and calories expended for overall health and weight management. By balancing calories, individuals can ensure they are meeting their nutritional needs without overeating or consuming excess calories. A: Balancing sodium and potassium is important for managing blood pressure, but this is not a specific guideline of the ChooseMyPlate program. B: Decreasing water consumption is not a guideline of the ChooseMyPlate program. Adequate hydration is essential for overall health. C: Increasing portion size is not recommended in the ChooseMyPlate program. It emphasizes portion control and eating appropriate serving sizes of different food groups.

Correct Answer: A

Rationale: The correct answer is A: Acute pain related to tissue manipulation and incision. This is the most likely major nursing diagnosis because post-surgical pain is a common and expected occurrence after breast surgery. The patient is likely to experience pain due to tissue manipulation and incision during the surgery. Addressing acute pain is crucial for the patient's comfort, well-being, and overall recovery. Choice B (Ineffective coping related to surgery) may be a secondary nursing diagnosis, but acute pain takes priority as it directly impacts the patient's immediate comfort and recovery. Choice C (Risk for trauma related to post-surgical injury) is not the most appropriate nursing diagnosis since the patient has already undergone surgery and is not at risk for further injury at this point. Choice D (Chronic sorrow related to change in body image) is not the most immediate concern post-surgery; addressing acute pain is more critical.