foundations of nursing test bank

Correct Answer: B

Rationale: The correct answer is B because it shows an understanding that being HIV-positive does not guarantee transmission to the baby. The statement acknowledges the possibility of the baby not being affected, which demonstrates awareness of the varying outcomes. Choice A is incorrect as it assumes abortion is the only option. Choice C is incorrect as it makes an extreme and inaccurate claim. Choice D is incorrect as pregnancy does not decrease the chance of developing AIDS.

Correct Answer: D

Rationale: The correct answer is D: Ensuring patient privacy. In the PLISSIT model, ensuring patient privacy is crucial as it creates a safe and confidential environment for discussing sensitive topics like sexual health. This step helps build trust and allows the patient to feel comfortable sharing intimate details. Briefly teaching about normal sexual physiology (A) may come later in the assessment process. Assuring confidentiality (B) is important but doesn't address the immediate need for privacy. Asking if the patient is willing to discuss sexual functioning (C) assumes patient readiness without first establishing a private setting.

Correct Answer: B

Rationale: The correct answer is B because it directly addresses the patient's ethnohistory by asking about the differences in their life here compared to back home. This question helps the nurse understand the patient's cultural background, beliefs, and practices. Option A focuses solely on language, which is not sufficient to understand ethnohistory. Option C inquires about caregivers during sickness, which is important but does not specifically relate to ethnohistory. Option D compares treatment approaches, which is relevant but doesn't explore the broader cultural context as effectively as option B.

Correct Answer: A

Rationale: The correct answer is A: Serum albumin level. Serum albumin is an important indicator of nutritional status, as low levels may indicate malnutrition or inflammation commonly seen in AIDS patients. Weight history (B) is also relevant as weight changes can reflect nutritional status. White blood cell count (C) is not directly related to nutritional status. Body mass index (D) is a calculation based on weight and height, not a direct measure of nutritional status. Blood urea nitrogen (E) is a measure of kidney function, not a specific indicator of nutritional status. Therefore, the nurse should primarily focus on assessing the patient's serum albumin level for nutritional status evaluation in this case.

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.