foundation of nursing questions and answers

Correct Answer: C

Rationale: The correct choice is C because if no urine is obtained, it indicates that the catheter is not in the urethra. The nurse should remove the catheter, wipe with alcohol to maintain cleanliness, and reinsert after lubrication to ensure proper placement in the urethra. This step-by-step approach allows for a more accurate catheter insertion and prevents potential complications. Choice A is incorrect as discarding the catheter and starting over without addressing the issue does not solve the problem. Choice B is incorrect as filling the balloon with sterile water is not relevant to the situation of catheter misplacement. Choice D is incorrect as leaving the catheter in the vagina can lead to infection and is not a recommended practice.

Correct Answer: B

Rationale: The correct answer is B because discussing the future indicates acceptance and hope, a positive step towards improved body image and self-esteem. The patient is focusing on moving forward, which shows emotional growth and resilience. Choice A may provide temporary comfort but does not necessarily address underlying emotional issues. Choice C is related to pain management, not body image or self-esteem. Choice D suggests continued emotional distress rather than progress towards improved self-image.

Correct Answer: C

Rationale: The correct answer is C because it provides specific, objective information about the patient's left knee incision, including its size and absence of concerning signs. This entry is relevant, concise, and focuses on a specific aspect of the patient's condition, aiding in continuity of care and treatment planning. Choice A is vague and lacks detail, making it insufficient for accurate patient care documentation. Choice B focuses on the patient's subjective feelings and does not provide objective assessment data. Choice D is judgmental and includes unnecessary information about the patient's behavior and family presence, which is not directly related to the patient's condition.

Correct Answer: A

Rationale: The correct answer is A: Impaired nutritional status. Radiation therapy to the neck can lead to mucositis, dysphagia, and taste changes, which can impair the patient's ability to eat and maintain adequate nutrition. This can lead to weight loss, weakness, and delayed wound healing. Discussing this potential adverse effect with the patient is crucial for proactive management. Choice B: Cognitive changes, and Choice C: Diarrhea are less likely to be direct adverse effects of radiation therapy to the neck. Cognitive changes are more commonly associated with brain radiation, while diarrhea is a more common side effect of abdominal radiation. Choice D: Alopecia is a side effect of chemotherapy, not radiation therapy. Radiation therapy does not typically cause hair loss unless it is in the treatment field. Therefore, discussing alopecia with the patient receiving radiation for a malignant neck tumor is not a priority.

Correct Answer: C

Rationale: The correct answer is C: Semisolid food with thick liquids. Patients with Parkinson's disease often have dysphagia, leading to aspiration and respiratory complications. Semisolid food with thick liquids helps prevent aspiration and promotes safer swallowing. TPN (A) is not necessary for meeting nutritional needs unless the patient cannot tolerate oral intake. A low-residue diet (B) may not address the specific swallowing issues in Parkinson's disease. Minced foods and fluid restriction (D) may not provide adequate nutrition and hydration.