foundations of nursing test bank

Correct Answer: C

Rationale: The correct answer is C: Is there someone you trust to help you make treatment choices? This question assesses the patient's support system and ability to make informed decisions, which are crucial in coping with a breast cancer diagnosis. It shows the nurse's consideration for the patient's emotional well-being and involvement in the decision-making process. Choice A: What is your level of education? This question is not directly related to coping with the diagnosis of breast cancer and may not provide relevant information about the patient's ability to cope. Choice B: Are you feeling alright these days? While this question shows concern for the patient's well-being, it does not specifically address coping mechanisms or support systems. Choice D: Are you concerned about receiving this diagnosis? This question focuses on the patient's emotional reaction to the diagnosis but does not directly assess coping strategies or support systems.

Correct Answer: B

Rationale: The correct answer is B: Healers. In the ETHNIC mnemonic, "H" stands for Healers, where the nurse assesses the individual's traditional healers, healthcare practices, and preferences for seeking healthcare. This is important in understanding the individual's cultural beliefs and practices related to health and treatment. Assessing "Health" (A) may be important, but it does not specifically address traditional healers. "History" (C) focuses on the individual's cultural background rather than healthcare practices. "Homeland" (D) pertains to the individual's place of origin, which is not directly related to healthcare communication.

Correct Answer: C

Rationale: Correct Answer: C - Administering an enema Rationale: Administering an enema is a task that can be safely delegated to nursing assistive personnel (NAP) as it is within their scope of practice and does not require the specialized knowledge and skills of a registered nurse. NAP can be trained to perform enema administration safely and effectively, under the supervision of a nurse. This task involves following a specific procedure and does not require clinical judgment or decision-making. Summary of other choices: A: Performing the first postoperative pouch change - This task involves wound care and assessment, which require the expertise of a registered nurse. B: Maintaining a nasogastric tube - This task involves ongoing assessment, monitoring for complications, and adjustments, which are responsibilities of a registered nurse. D: Digitally removing stool - This task involves invasive procedures and assessment, which are beyond the scope of practice for nursing assistive personnel.

Correct Answer: B

Rationale: The correct answer is B: Vulvodynia. Vulvodynia is characterized by chronic vulvar pain or discomfort, including stabbing pain and burning, without an identifiable cause. In this case, the young girl is experiencing these symptoms despite not being sexually active, ruling out other conditions like vulvitis (inflammation of the vulva), vaginitis (inflammation of the vagina), and Bartholin's cyst (fluid-filled swelling near the vaginal opening). The absence of sexual activity suggests that the pain is not related to an infection or trauma, further supporting the diagnosis of vulvodynia.

Correct Answer: B

Rationale: The correct answer is B because giving a hypertonic solution enema to a patient with fluid volume excess can worsen the condition by drawing more fluid into the colon. This can lead to further fluid volume overload and electrolyte imbalances. The other choices are incorrect because: A: Normal saline enema is appropriate for constipation. C: Kayexalate enema is used to treat hyperkalemia, not hypokalemia. D: Oil retention enema is indicated for constipation to soften stool.