foundations of nursing practice questions

Correct Answer: B

Rationale: The correct answer is B: Acute pain related to misplaced endometrial tissue. This nursing diagnosis should be prioritized because endometriosis commonly presents with severe pelvic pain. Managing pain is crucial for the patient's comfort and quality of life. Anxiety (choice A) is not the priority as pain management takes precedence. Ineffective tissue perfusion (choice C) is not a priority unless the patient is actively hemorrhaging. Excess fluid volume (choice D) is not typically associated with endometriosis. Prioritizing pain management will address the immediate and most distressing symptom for the patient.

Correct Answer: D

Rationale: The correct answer is D because setting the scanner to female is incorrect for a patient who has had a hysterectomy as they do not have a uterus. This could lead to inaccurate results. Palpating the symphysis pubis (A) ensures proper positioning, wiping the scanner head with alcohol (B) maintains infection control, and applying gel (C) facilitates sound wave transmission.

Correct Answer: C

Rationale: The correct answer is C: Degree of glycemic control before and during the pregnancy. Proper glycemic control is crucial in managing complications in a pregnant patient with diabetes. Uncontrolled blood sugar levels can lead to maternal, fetal, and neonatal complications. Monitoring and maintaining stable blood glucose levels before and during pregnancy help reduce the risk of adverse outcomes. A: Evaluation of retinopathy by an ophthalmologist - Although important for overall health, retinopathy does not directly impact maternal, fetal, and neonatal complications in diabetes during pregnancy. B: The patient�s stable emotional and psychological status - While emotional and psychological well-being are important, they do not directly affect complications related to diabetes in pregnancy. D: Total protein excretion and creatinine clearance within normal limits - While these are indicators of kidney function, they are not the most crucial factors in managing complications in a pregnant patient with diabetes.

Correct Answer: A

Rationale: The correct answer is A: Hypoactive bowel sounds. When a patient has not had a bowel movement in 3 days, it indicates constipation. Constipation can lead to decreased peristalsis, resulting in hypoactive bowel sounds. Increased fluid intake (B) would be a potential intervention, not an expected assessment finding. A soft tender abdomen (C) may indicate other issues like inflammation or infection, not directly related to constipation. Jaundice in the sclera (D) is indicative of liver dysfunction, not a typical finding associated with constipation.

Correct Answer: D

Rationale: The correct answer is D: Discuss a referral for hospice care. Hospice care provides specialized care for patients with terminal illnesses, focusing on comfort and quality of life. This option aligns with the patient's wish to die at home and ensures his care needs are met. Hospice care also provides emotional and spiritual support for both the patient and family. A: Discuss a referral for rehabilitation hospital - This option focuses on rehabilitation, which is not suitable for a patient with a terminal illness like extensive stage small-cell lung cancer. B: Panel the patient for a personal care home - Personal care homes may not provide the level of specialized care needed for a terminally ill patient. C: Discuss a referral for acute care - Acute care is more focused on treating acute illnesses and injuries, not providing end-of-life care for a patient with a terminal illness.