foundation of nursing practice questions

Correct Answer: A

Rationale: The most appropriate nursing intervention for a patient with AIDS experiencing extreme anxiety is to teach the patient guided imagery. Guided imagery is a relaxation technique that can help the patient reduce anxiety levels, promote a sense of calm, and improve overall well-being. By teaching the patient how to use guided imagery, the nurse empowers the patient to manage her anxiety in a non-pharmacological way. This intervention promotes self-care and allows the patient to have a tool to use independently beyond the hospital setting. Giving the patient more control of her antiretroviral regimen may be beneficial for adherence but does not directly address the anxiety symptoms. Increasing the patient's activity level may be helpful for overall well-being but may not specifically target the extreme anxiety. Collaborating with the patient's physician to obtain an order for hydromorphone, a potent opioid medication, is not appropriate unless it is indicated for severe pain management, not anxiety.

Correct Answer: D

Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.

Correct Answer: A

Rationale: In the assessment of a patient with potential placenta previa or abruptio placentae, the nurse should pay close attention to the amount and characteristics of vaginal bleeding. Placenta previa typically presents with painless vaginal bleeding, which can be sudden and significant. Therefore, a saturated perineal pad within a short period of time (1 hour) is more indicative of placenta previa, as opposed to abruptio placentae which usually presents with painful vaginal bleeding and may not necessarily saturate a perineal pad quickly. Monitoring the amount of bleeding and keeping track of pad saturation over time can provide valuable information to differentiate between these two conditions.

Correct Answer: D

Rationale: Black or tarry stools can be caused by certain medications and supplements, such as iron supplements. Since the fecal occult test is negative, it indicates that bleeding is not occurring. Therefore, in this situation, it is important to consider factors that can affect the color of stool, including iron supplementation. Addressing this question can help determine the cause of the black stool and provide appropriate guidance or reassurance to the patient. This response shows a comprehensive understanding of potential causes and demonstrates a thoughtful approach in addressing the patient's concern.

Correct Answer: A

Rationale: Effective breast self-examination (BSE) relies significantly on women's knowledge of their own breasts. Understanding how their breasts normally look and feel allows women to detect any changes such as lumps, dimpling, or discharge, which may be early signs of breast abnormalities like cancer. By being familiar with their breasts' normal appearance and texture, women can promptly seek medical attention if they notice any unusual changes. This self-awareness and familiarity with their breasts are crucial in enabling women to perform BSE effectively and to detect any potential issues early on.