foundations of nursing test bank

Correct Answer: B

Rationale: The correct answer is B: Ensuring that the patient receives adequate palliative care. Palliative care focuses on improving the quality of life for patients with serious illnesses, including managing symptoms and providing emotional support. In this case, since the patient is not receiving treatment for her brain metastases, palliative care would be most appropriate to help alleviate any pain or discomfort she may be experiencing and provide holistic support for her and her family. A: Promoting the patient's functional status and ADLs may not be the priority if the patient's prognosis is terminal and she is not receiving treatment for her brain metastases. C: Ensuring that the family does not tell the patient her condition is terminal goes against ethical principles of honesty and transparency in healthcare. D: Promoting adherence to the prescribed medication regimen may not be relevant if the patient is not receiving active treatment for her brain metastases.

Correct Answer: C

Rationale: The correct answer is C: Identifying the offending agent, if possible. This is prioritized in contact dermatitis to prevent further exposure and recurrence. By identifying the specific irritant or allergen, the nurse can guide the patient in avoiding it, leading to effective management. Choices A, B, and D are incorrect because while promoting adequate perfusion, safe use of topical antihistamines, and teaching the use of an EpiPen may be relevant in certain situations, they do not directly address the root cause of contact dermatitis, which is exposure to the offending agent.

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.

Correct Answer: D

Rationale: The correct answer is D: Improved coping with lifestyle modifications. This outcome is appropriate for a patient with allergic rhinitis as it focuses on helping the patient manage the condition through lifestyle changes, such as avoiding allergens and using medications as prescribed. By improving coping skills, the patient can better manage symptoms and reduce the impact of allergic rhinitis on daily life. Rationale: 1. A: Appropriate use of prophylactic antibiotics is not relevant for allergic rhinitis, which is not typically treated with antibiotics. 2. B: Safe injection of corticosteroids is not a primary treatment for allergic rhinitis and may not be necessary for all patients. 3. C: Improved skin integrity is not a priority outcome for allergic rhinitis, as it primarily affects the respiratory system, not the skin. Summary: Improving coping with lifestyle modifications is the most relevant outcome for a patient with allergic rhinitis, as it addresses the management of symptoms and overall quality of

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis. 2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents. 3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications. Summary: A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario. B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident. C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.