foundations of nursing practice questions

Correct Answer: C

Rationale: The correct answer is C: Assist to a standing position. This action helps utilize gravity to aid in emptying the bladder and may help the patient void without the need for invasive measures like catheterization or medications. It is a non-invasive and natural approach to promote urination. Limiting fluid intake (A) could worsen the situation by concentrating urine and worsening retention. Inserting a urinary catheter (B) should be considered only if other measures fail. Asking for a diuretic medication (D) does not address the immediate need for bladder emptying and may not be necessary if the patient can void naturally.

Correct Answer: A

Rationale: Step 1: In Campinha-Bacote's model, the first component is "cultural awareness," which involves an in-depth self-examination of one's own background. Step 2: This self-examination helps nurses recognize their biases and assumptions, enabling them to provide culturally competent care. Step 3: By understanding their own culture, nurses can better understand and respect the cultural beliefs and practices of their patients. Step 4: This component is crucial for building trust and rapport with patients from diverse backgrounds. Step 5: Choices B, C, and D do not directly align with the cultural awareness component of Campinha-Bacote's model. B focuses on assessment, C on understanding diverse groups, and D on motivation, but they do not address the foundational self-examination required for cultural competency.

Correct Answer: C

Rationale: The correct answer is C: The patient's vomiting is unrelated to food intake. In the context of a brain tumor, vomiting that is not related to food intake can indicate increased intracranial pressure affecting the brain's vomiting center. This is known as projectile vomiting. A: Vomiting accompanied by epistaxis (nosebleeds) is more indicative of other conditions like hypertension or nasal issues, not necessarily specific to a brain tumor. B: Vomiting not relieving nausea can be seen in various conditions affecting the gastrointestinal system, not specifically brain tumors. D: Blood-tinged emesis can suggest gastrointestinal bleeding or other issues, but it's not a specific characteristic of vomiting associated with brain tumors.

Correct Answer: C

Rationale: The correct answer is C: Women over age 40. Annual clinical breast examinations are recommended for this population group because they have an increased risk of developing breast cancer compared to younger age groups. Regular screenings starting at age 40 can help in early detection and improve survival rates. A: Women over age 21 - This age group is generally recommended to start clinical breast examinations every 1-3 years, not necessarily annually. B: Women over age 25 - While it's important to be vigilant about breast health, the risk of breast cancer increases with age, making annual exams more crucial for older women. D: All post-pubescent females with a family history of breast cancer - While family history is a risk factor, the recommendation for annual clinical breast examinations typically begins at age 40, regardless of family history.

Correct Answer: A

Rationale: The correct answer is A: Type I hypersensitivity reaction. This type of reaction involves the release of histamine from mast cells and basophils, leading to symptoms like hives. It is characterized by the involvement of IgE antibodies. In this case, the patient developed hives quickly after exposure to the allergen, indicating an immediate hypersensitivity reaction typical of Type I. Choices B, C, and D are incorrect because they are associated with different mechanisms and timeframes of hypersensitivity reactions. Type II involves antibody-mediated cell destruction, Type III involves immune complex deposition, and Type IV is a delayed-type hypersensitivity reaction mediated by T cells, none of which are consistent with the rapid onset of hives seen in this patient.