foundation of nursing practice questions

Correct Answer: B

Rationale: B. Overall psychological functioning: It is crucial for the home care nurse to assess the patient's overall psychological functioning after a total mastectomy without reconstruction. The patient may be experiencing emotional distress, body image disturbances, anxiety, or depression related to the surgery and changes in physical appearance. The nurse should evaluate the patient's coping mechanisms, emotional well-being, and any signs of psychological implications to provide appropriate support and referral for mental health services if needed.

Correct Answer: C

Rationale: Phimosis is a condition in which the foreskin of the penis is tight and cannot be retracted over the glans. It can occur in uncircumcised males, like the 78-year-old male in this scenario. Phimosis may lead to difficulty with hygiene, pain during sexual activity, and an increased risk of infections. Treatment may involve conservative measures such as topical corticosteroids or, in severe cases, surgical intervention like circumcision to alleviate the tightness of the foreskin.

Correct Answer: A

Rationale: The most critical assessment parameter to include in the initial assessment of a patient with a brain tumor scheduled for surgery is the gag reflex. The gag reflex is a protective mechanism that prevents the entry of foreign objects into the airway and lungs. Patients undergoing brain tumor resection may be at risk for impaired gag reflex due to the effects of the tumor on cranial nerves or related structures. Identifying any impairment in the gag reflex is essential to prevent aspiration during and after the surgical procedure. Monitoring the gag reflex allows the healthcare team to take necessary precautions to protect the patient's airway and prevent complications. Therefore, assessing the gag reflex is crucial in the care of a patient with a brain tumor undergoing surgery.

Correct Answer: C

Rationale: The most appropriate action for the home health nurse to take in this situation where a patient reports distortions when looking at an Amsler grid is to arrange for the patient to be assessed for macular degeneration. Distortions in straight lines on an Amsler grid are a common early symptom of macular degeneration, a progressive eye condition that affects central vision. Macular degeneration is a leading cause of vision loss in older adults, making assessment and early intervention crucial in preserving vision. It is important for the nurse to take the patient's symptoms seriously and facilitate timely evaluation and management to prevent further vision loss. This would involve referring the patient to an ophthalmologist or an eye care specialist for a comprehensive evaluation and appropriate treatment.

Correct Answer: C

Rationale: Distorted lines on an Amsler grid can be an indication of changes in central vision, which is commonly seen in macular degeneration. Therefore, it is crucial for the nurse to arrange for the patient to visit his ophthalmologist promptly for further evaluation and management. The ophthalmologist will be able to determine the severity of the visual changes, provide appropriate treatment options, and closely monitor the progression of macular degeneration. This proactive approach ensures that the patient receives timely and specialized care for his condition. Options A, B, and D do not directly address the urgency of the situation and the need for specialized ophthalmologic evaluation in cases of macular degeneration.