foundation of nursing questions and answers

Correct Answer: A

Rationale: The correct answer is A: Disturbed Body Image Related to Effects of Surgery. This nursing diagnosis is appropriate because the patient expresses concerns about feeling emasculated and a shell of a man after the surgery, indicating a disturbance in his body image. The patient's perception of how the surgery will affect his masculinity is a clear indication of body image disturbance. Choice B is incorrect because there is no mention of spiritual distress in the patient's statements. Choice C is incorrect as there is no indication that the patient will experience social isolation specifically related to the surgery. Choice D is incorrect as the patient's concerns are primarily related to his body image and not loneliness.

Correct Answer: B

Rationale: The correct answer is B because brachytherapy does not pose a risk to the patient's daughter or her unborn child. Brachytherapy involves placing radioactive sources inside or near the tumor, which does not make the patient radioactive. The radiation does not travel far and does not pose a risk to others. Therefore, the daughter and her infant are safe from any radiation exposure. Choices A, C, and D are incorrect because there is no need for the patient to avoid contact with the baby after delivery, the brachytherapy is not contraindicated for safety reasons, and there is no requirement for the patient to avoid close contact with his daughter for 2 months.

Correct Answer: A

Rationale: The correct answer is A: The patient's hearing is likely normal. This interpretation is based on the normal Rinne test result, where air-conducted sound is expected to be louder than bone-conducted sound. This finding indicates that the patient has intact air conduction and no significant conductive hearing loss. Option B is incorrect because tinnitus is not directly related to the Rinne test results. Option C is incorrect as otosclerosis would typically present with abnormal Rinne test results showing bone-conducted sound to be louder. Option D is incorrect as sensorineural hearing loss would not typically affect the Rinne test results in this way.

Correct Answer: A

Rationale: The correct answer is A because understanding how a patient perceives and reacts to their illness is crucial for providing holistic care. By focusing on the patient's perspective, the nurse can address their emotional, mental, and social needs. Choice B is incorrect as it only considers biological aspects. Choice C is incorrect as it only focuses on psychological processes. Choice D is incorrect as it does not directly address the patient's perspective on illness. A holistic approach that considers the patient's meaning of illness is essential for providing patient-centered care.

Correct Answer: B

Rationale: The correct answer is B: Uterine infection. The patient's symptoms of crampy abdominal pain, scant serosanguineous vaginal drainage with odor, negative pregnancy test, and vital signs indicating fever, low blood pressure, and irregular pulse suggest an infection. The history of recent miscarriage raises suspicion for retained products of conception leading to infection. Ectopic pregnancy (choice A) would present with different symptoms such as abdominal pain, vaginal bleeding, and positive pregnancy test. Gestational trophoblastic disease (choice C) typically presents with abnormal vaginal bleeding and high levels of hCG. Endometriosis (choice D) is a chronic condition and not related to the acute symptoms described. In summary, the clinical presentation aligns with uterine infection given the patient's history, symptoms, and vital signs.