foundation of nursing questions

Correct Answer: B

Rationale: The correct answer is B: Implement precautions to ensure the patient's safety. When a patient exhibits seizure activity for the first time, the immediate priority is to ensure the patient's safety by implementing precautions such as protecting the patient from injury during the seizure, ensuring a patent airway, and monitoring vital signs. Identifying triggers (Choice A) can be important for long-term management but is not the priority during an acute seizure. Teaching the family about the relationship between brain tumors and seizures (Choice C) can be done later but is not the immediate priority. Ensuring a private room (Choice D) is not the priority when the patient's safety during a seizure is the main concern.

Correct Answer: C

Rationale: The correct answer is C: Narrative. The nurse is using a narrative interaction by asking the patient to share a personal story. This helps the patient express their experiences, emotions, and perspectives, promoting a deeper understanding of their care needs. A: Nonjudgmental is incorrect as it focuses on avoiding biases. B: Socializing is incorrect as it implies casual conversation. D: SBAR is incorrect as it stands for Situation, Background, Assessment, and Recommendation, used for concise communication in healthcare settings.

Correct Answer: C

Rationale: Step 1: Trigeminal neuralgia involves severe facial pain, often triggered by touch or movement. Step 2: Rubbing the eye on the affected side can trigger pain due to the trigeminal nerve involvement. Step 3: Therefore, advising the patient to avoid rubbing the eye on the affected side is crucial to prevent pain exacerbation and potential injury. Step 4: Choices A, B, and D are incorrect as they do not directly address the risk of injury related to trigeminal neuralgia.

Correct Answer: C

Rationale: The correct answer is C: �Drink your nightly glass of milk earlier in the evening.� By suggesting the patient to drink milk earlier, it allows more time for the body to process and excrete the fluids before bedtime, reducing the likelihood of bedwetting. This intervention targets the root cause of the issue by addressing the timing of fluid intake. Explanation for why the other choices are incorrect: A: �Set your alarm clock to wake you every 2 hours, so you can get up to void.� This intervention disrupts the patient's sleep pattern and may not address the underlying cause of bedwetting. B: �Line your bedding with plastic sheets to protect your mattress.� This intervention focuses on managing the consequences of bedwetting rather than preventing it. D: �Empty your bladder completely before going to bed.� While important, this suggestion alone may not be sufficient to address the timing of fluid intake, which is crucial in reducing bedwetting frequency.

Correct Answer: A

Rationale: The correct answer is A: A referral for a mammogram. Given the family history of breast cancer in the patient's father, the nurse should recommend a mammogram as a preventive measure due to increased risk. Mammograms are effective in detecting breast cancer early, especially in individuals with a family history. This can help in early diagnosis and timely intervention if needed. B: Instructions about breast self-examination (BSE) can be helpful, but in this case, a mammogram is a more definitive screening tool for high-risk individuals. C: A referral to a surgeon is not necessary at this point as the patient does not exhibit any symptoms of breast cancer. D: Referral to a support group may be beneficial for emotional support, but the priority should be on proactive screening measures like a mammogram.