foundations of nursing test bank

Correct Answer: C

Rationale: Step 1: After mastoid surgery, patients may experience pain and dizziness, hence addressing the safe use of analgesics and antivertiginous agents is crucial for symptom management. Step 2: Analgesics help in managing post-operative pain, while antivertiginous agents help control dizziness, reducing the risk of falls. Step 3: Educating the patient on safe use ensures proper pain and symptom management, preventing complications. Step 4: Other choices are incorrect as they do not directly address immediate post-operative care needs such as pain and dizziness management.

Correct Answer: A

Rationale: The correct answer is A: Diabetic retinopathy. This is because diabetic retinopathy is a leading cause of blindness in adults over 40, resulting from diabetes affecting blood vessels in the retina. Trauma (B) is a common cause of visual impairment but not as prevalent as diabetic retinopathy in this age group. Macular degeneration (C) primarily affects older individuals, typically over 50, rather than those over 40. Cytomegalovirus (D) is a cause of blindness in immunocompromised individuals, not specific to the age group mentioned. Glaucoma (E) is a leading cause of blindness worldwide but is more common in older adults and not specifically over 40.

Correct Answer: C

Rationale: The correct answer is C because providing realistic emotional preparation for death is a priority in caring for a patient with a terminal illness like leukemia. This helps the patient and their loved ones cope with the impending loss and make the most of the time left. Option A focuses solely on prolonging life, which may not align with the patient's wishes. Option B, providing financial advice, is important but not the top priority in this situation. Option D, maximizing family social interactions after the patient's death, is not immediate and does not address the patient's emotional needs.

Correct Answer: D

Rationale: The correct answer is D because the patient's symptoms of pounding headache, visual changes, and epigastric pain are classic signs of worsening preeclampsia, indicating a significant increase in blood pressure and potential progression to eclampsia (seizures). Immediate medical intervention is crucial to prevent complications. A: Gastrointestinal upset does not explain the combination of symptoms presented. B: Magnesium sulfate is used to prevent seizures in preeclampsia but does not cause these specific symptoms. C: Anxiety does not typically present with the specific physical symptoms mentioned.

Correct Answer: A

Rationale: The correct answer is A: Assessing for mouth droop and decreased lateral eye gaze. After a radical mastoidectomy, the nurse should prioritize assessing for signs of facial nerve damage, such as mouth droop and decreased lateral eye gaze, which can indicate injury to the facial nerve during surgery. This is crucial as immediate intervention may be needed to prevent long-term complications. Choices B, C, and D are incorrect: B: Assessing for increased middle ear pressure and perforated ear drum is not the priority postoperative care for a radical mastoidectomy patient. C: Assessing for gradual onset of conductive hearing loss and nystagmus is not the priority as these are not immediate concerns postoperatively. D: Assessing for scar tissue and cerumen obstructing the auditory canal is not the priority as these are not immediate postoperative complications that require urgent attention.