foundation of nursing questions

Correct Answer: B

Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention. Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B. Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B. Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.

Correct Answer: B

Rationale: The correct answer is B: Decreased skin turgor. Diarrhea leads to fluid loss, causing dehydration and decreased skin turgor. This indicates the patient's hydration status. A: Distended abdomen is more common in conditions like bowel obstruction, not necessarily in diarrhea. C: Increased energy levels are unlikely due to the patient's weakened state from dehydration. D: Elevated blood pressure is not typically associated with dehydration.

Correct Answer: D

Rationale: The correct answer is D: Duodenum. The duodenum is the first part of the small intestine where most of the digestion and absorption of nutrients occurs. It receives partially digested food from the stomach and mixes it with bile and pancreatic enzymes to break down nutrients. The villi in the duodenum increase the surface area for absorption. The other choices (A: Ileum, B: Cecum, C: Stomach) are incorrect because the ileum and cecum are parts of the small intestine where some absorption occurs but not as much as in the duodenum. The stomach primarily digests food and does not absorb many nutrients.

Correct Answer: D

Rationale: Step 1: Providing encouragement is essential to building trust and rapport with the patient, which is crucial in supporting her emotional needs. Step 2: Empathy helps the patient feel understood and supported, fostering a positive therapeutic relationship. Step 3: Thoughtful encouragement acknowledges the patient's feelings and validates her experiences, empowering her to gradually accept her body changes. Step 4: By offering empathic and thoughtful encouragement, the nurse helps the patient develop a positive body image at her own pace. Choice A focuses on physical appearance, Choice B generalizes experiences, and Choice C overlooks the patient's emotional journey.

Correct Answer: D

Rationale: The correct answer is D: Obese. This classification is based on the Body Mass Index (BMI) calculation, which takes into account weight and height. A BMI above 30 is considered obese, indicating excess body fat. Other choices are incorrect because they do not align with the BMI criteria for obesity. Choice A is incorrect as normal weight falls within a specific BMI range. Choice B is incorrect for individuals with a BMI below the normal range. Choice C is incorrect for individuals with a BMI between the overweight and obese categories.