test bank foundations of nursing

Correct Answer: A

Rationale: The correct answer is A: Disturbed body image. Enucleation can have a significant impact on a patient's self-image and self-esteem. By addressing this nursing diagnosis, the nurse can help the patient cope with the changes in their physical appearance and support them in adjusting to wearing a prosthesis. Summary: - Choice B (Chronic pain) is incorrect because enucleation may cause acute pain initially, but chronic pain is not a common concern post-enucleation. - Choice C (Ineffective protection) is incorrect because enucleation does not necessarily affect the eye's protection mechanism. - Choice D (Unilateral neglect) is incorrect as it refers to a neurological condition unrelated to the patient's situation post-enucleation.

Correct Answer: D

Rationale: The correct answer is D: Asthma. Atopic dermatitis is associated with a heightened immune response and inflammation, which can predispose individuals to developing asthma. Both conditions involve an overactive immune response and can coexist in patients due to shared genetic and environmental factors. Asthma commonly presents alongside atopic dermatitis in individuals with atopic tendencies. Bronchitis (choice A) is a respiratory condition caused by inflammation of the bronchial tubes and is not directly linked to atopic dermatitis. Systemic lupus erythematosus (choice B) and rheumatoid arthritis (choice C) are autoimmune diseases that primarily affect the joints and other organs, but they are not typically associated with atopic dermatitis.

Correct Answer: A

Rationale: The correct answer is A: Hyperglycemia. The patient's symptoms like lethargy, thirst, headache, increased urination are indicative of high blood sugar levels. Lethargy is a common symptom of hyperglycemia due to the body's inability to use glucose effectively. Thirst and increased urination occur as the body tries to get rid of excess glucose through urine. Headache can result from dehydration due to increased urination. To address hyperglycemia, the nurse may need to adjust the patient's parenteral nutrition, monitor blood glucose levels, and potentially administer insulin. Incorrect choices: B: Hypoglycemia - Symptoms of hypoglycemia include sweating, confusion, and shakiness, which are not present in this case. C: Hypercapnia - This is high carbon dioxide levels in the blood, typically caused by respiratory issues, not related to the symptoms described. D: Hypocapnia - This is low carbon dioxide levels

Correct Answer: D

Rationale: Correct Answer: D - Proper hand hygiene techniques Rationale: 1. Clostridium difficile is mainly spread through contact with contaminated surfaces. 2. Proper hand hygiene is the most effective way to prevent the spread of bacteria. 3. Hand hygiene removes bacteria from hands, reducing the risk of transmission. 4. Appropriate disposal (A) is important but doesn't directly prevent spread. Monthly in-services (B) and mandatory cultures (C) are not as effective as hand hygiene in preventing transmission.

Correct Answer: B

Rationale: The correct answer is B: Human papillomavirus (HPV). HPV is the most important risk factor for cervical cancer as it is responsible for almost all cases. Step 1: HPV infection can lead to changes in cervical cells, increasing the risk of cancer. Step 2: Early detection and vaccination against HPV can prevent cervical cancer. Step 3: Other factors like late childbearing, postmenopausal bleeding, and tobacco use may be associated with increased risk but are not as directly linked to cervical cancer development.