foundations of nursing test bank

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: Correct Answer: C - Administering an enema Rationale: Administering an enema is a task that can be safely delegated to nursing assistive personnel (NAP) as it is within their scope of practice and does not require the specialized knowledge and skills of a registered nurse. NAP can be trained to perform enema administration safely and effectively, under the supervision of a nurse. This task involves following a specific procedure and does not require clinical judgment or decision-making. Summary of other choices: A: Performing the first postoperative pouch change - This task involves wound care and assessment, which require the expertise of a registered nurse. B: Maintaining a nasogastric tube - This task involves ongoing assessment, monitoring for complications, and adjustments, which are responsibilities of a registered nurse. D: Digitally removing stool - This task involves invasive procedures and assessment, which are beyond the scope of practice for nursing assistive personnel.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis. 2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents. 3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications. Summary: A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario. B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident. C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.

Correct Answer: A

Rationale: The correct answer is A: Acute pain related to tissue manipulation and incision. This is the most likely major nursing diagnosis because post-surgical pain is a common and expected occurrence after breast surgery. The patient is likely to experience pain due to tissue manipulation and incision during the surgery. Addressing acute pain is crucial for the patient's comfort, well-being, and overall recovery. Choice B (Ineffective coping related to surgery) may be a secondary nursing diagnosis, but acute pain takes priority as it directly impacts the patient's immediate comfort and recovery. Choice C (Risk for trauma related to post-surgical injury) is not the most appropriate nursing diagnosis since the patient has already undergone surgery and is not at risk for further injury at this point. Choice D (Chronic sorrow related to change in body image) is not the most immediate concern post-surgery; addressing acute pain is more critical.

Correct Answer: C

Rationale: The correct answer is C: "You are anxious about the surgery. Do you see smoking as helping?" This response acknowledges the patient's anxiety and invites him to explore his reasons for wanting to smoke, opening up a dialogue and potentially uncovering underlying issues. It also avoids judgment or direct orders, fostering a therapeutic nurse-patient relationship. Explanation of why the other choices are incorrect: A: "Smoking is the reason you are here." - This response is blaming and may increase the patient's guilt or anxiety, hindering effective communication. B: "The doctor left orders for you not to smoke." - This response is authoritative and may lead to resistance or defensiveness from the patient, rather than addressing his concerns. D: "Smoking is OK right now, but after your surgery it is contraindicated." - This response is unclear and may send mixed messages to the patient, potentially leading to confusion or misunderstanding.