foundation of nursing practice questions

Correct Answer: A

Rationale: Challenging communication situations in nursing care typically involve patients who exhibit behaviors that make communication difficult or complex. In the given options, a child who is developmentally delayed (Option A) and an older-adult patient who is demanding (Option B) are examples of patients who may have challenging communication issues.

Correct Answer: C

Rationale: In this scenario, the patient who has had a cervical diskectomy is experiencing severe pain with a sudden onset, which can be indicative of a complication such as bleeding, infection, or nerve impingement. The nurse's most appropriate action is to call the surgeon immediately to report the patient's pain. The surgeon needs to be informed promptly so that a further assessment can be made and appropriate interventions can be initiated to address the cause of the sudden pain. Palpating the surgical site or removing the dressing without consulting the surgeon first may worsen the situation or increase the risk of complications. Administering an NSAID is not appropriate in this situation without further evaluation and guidance from the surgeon. It is essential to prioritize patient safety and ensure that the patient receives timely and appropriate care by involving the surgeon in the decision-making process.

Correct Answer: A

Rationale: The statement "If I get a blue color that means the test is negative" given by the patient indicates the need for further education. This is incorrect information because a blue color in the guaiac test indicates a positive result, which means the presence of fecal occult blood. The patient should be taught that a positive result indicates the need for further evaluation and follow-up with their healthcare provider. Proper understanding of the test results is vital to ensure accurate interpretation and appropriate management. Further clarification and education are necessary to correct this misconception and guide the patient towards understanding the significance of a positive result.

Correct Answer: A

Rationale: A nurse assessing a patient with an acoustic neuroma would likely find symptoms such as loss of hearing, tinnitus, and vertigo. Acoustic neuroma, also known as vestibular schwannoma, is a noncancerous tumor that develops on the vestibulocochlear nerve, which carries sound and balance signals from the inner ear to the brain. The most common symptoms of an acoustic neuroma include progressive hearing loss, ringing in the ears (tinnitus), and dizziness or imbalance (vertigo). Therefore, option A is the most appropriate choice for the symptoms that the nurse is likely to find in a patient with an acoustic neuroma.

Correct Answer: A

Rationale: A. Using a lip lubricant can help keep the lips moist and prevent further irritation caused by the yeast infection.