foundations of nursing test bank

Correct Answer: D

Rationale: Correct Answer: D - Avoid rubbing or scratching the affected area Rationale: 1. Rubbing or scratching can further damage the already compromised skin integrity. 2. By avoiding rubbing or scratching, the patient reduces the risk of infection and delayed healing. 3. This intervention promotes skin healing and prevents worsening of the condition. Summary: A: Applying ice pack or heating pad may provide temporary relief but does not address the root cause of impaired skin integrity. B: Avoiding skin contact with water is not necessary and may not directly improve skin integrity. C: Phototherapy is not indicated for erythematous reactions to radiation therapy and may not address the issue.

Correct Answer: B

Rationale: The correct answer is B: Medication adverse effects. Gynecomastia in a 60-year-old man is often caused by medications like spironolactone, cimetidine, and certain antipsychotics. To determine the causative factor, a thorough medication history review is crucial. Age-related physiologic changes (choice A) do not typically lead to gynecomastia in men. Poor nutrition (choice C) and fluid overload (choice D) are not common causes of gynecomastia in this context.

Correct Answer: B

Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction. Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.

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: B

Rationale: The correct answer is B because it directly addresses the patient's ethnohistory by asking about the differences in their life here compared to back home. This question helps the nurse understand the patient's cultural background, beliefs, and practices. Option A focuses solely on language, which is not sufficient to understand ethnohistory. Option C inquires about caregivers during sickness, which is important but does not specifically relate to ethnohistory. Option D compares treatment approaches, which is relevant but doesn't explore the broader cultural context as effectively as option B.