foundations of nursing test bank

Correct Answer: B

Rationale: Step 1: Immunotherapy injections can cause allergic reactions. Step 2: Monitoring post-injection is crucial to detect and manage any potential adverse reactions promptly. Step 3: Staying in the clinic for 30 minutes allows for immediate intervention if needed. Step 4: This ensures patient safety and reduces the risk of severe reactions. Summary: A: Epinephrine is not typically given before immunotherapy injections. C: Therapeutic response may take longer than 3 months to show. D: Immunotherapy is usually given via subcutaneous route, not intravenous.

Correct Answer: C

Rationale: The correct answer is C because it accurately explains the physiological change in the eye that leads to the need for bifocals. As individuals age, there is a gradual thickening of the lens of the eye, which affects the eye's ability to accommodate for near vision. This thickening makes it harder for the eye to focus on close objects, necessitating the use of bifocals to correct this near vision issue. Choices A, B, and D are incorrect because they do not provide a scientifically accurate explanation for the need for bifocals in older individuals. Option A is dismissive and does not address the specific change in the eye that leads to the need for bifocals. Option B implies aging as a general concept without specifying the relevant change in the eye. Option D incorrectly states that the eye gets shorter as we age, which is not the reason for needing bifocals.

Correct Answer: D

Rationale: The correct answer is D: Bilateral mastectomy. This intervention involves removing both breasts to reduce the risk of developing breast cancer in the future. For a woman with a history of breast cancer in one breast, opting for bilateral mastectomy can significantly decrease the likelihood of cancer recurrence. This proactive approach is often recommended for individuals with a high risk of developing breast cancer. Explanation for why the other choices are incorrect: A: More aggressive chemotherapy - Chemotherapy is typically used to treat existing cancer cells, not as a prophylactic measure to prevent cancer. B: Left mastectomy - This option only removes the affected breast, not addressing the risk of cancer developing in the other breast. C: Radiation therapy - While radiation therapy can be used as part of the treatment for breast cancer, it is not a prophylactic measure to prevent future cancer development in the contralateral breast.

Correct Answer: B

Rationale: The correct answer is B: Ensuring that the patient receives adequate palliative care. Palliative care focuses on improving the quality of life for patients with serious illnesses, including managing symptoms and providing emotional support. In this case, since the patient is not receiving treatment for her brain metastases, palliative care would be most appropriate to help alleviate any pain or discomfort she may be experiencing and provide holistic support for her and her family. A: Promoting the patient's functional status and ADLs may not be the priority if the patient's prognosis is terminal and she is not receiving treatment for her brain metastases. C: Ensuring that the family does not tell the patient her condition is terminal goes against ethical principles of honesty and transparency in healthcare. D: Promoting adherence to the prescribed medication regimen may not be relevant if the patient is not receiving active treatment for her brain metastases.

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.