foundations of nursing test bank

Questions 100

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foundations of nursing test bank Questions

Question 1 of 5

An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?

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.

Question 2 of 5

A student nurse is doing clinical hours at an OB/GYN clinic. The student is helping to develop a plan of care for a patient with gonorrhea who has presented at the clinic. The student should include which of the following in the care plan for this patient?

Correct Answer: D

Rationale: Correct Answer: D - The patient should also be treated for chlamydia. Rationale: 1. Gonorrhea and chlamydia often coexist, so it is crucial to treat both infections to prevent complications. 2. Treating only gonorrhea may not fully resolve the patient's symptoms or prevent reinfection. 3. Dual therapy for gonorrhea and chlamydia is recommended to ensure optimal care for the patient. Summary of Incorrect Choices: A: The patient may benefit from oral contraceptives - This is not directly related to the treatment of gonorrhea. B: The patient must avoid use of tampons - This is not a standard recommendation for managing gonorrhea. C: The patient is susceptible to urinary incontinence - This is not a typical complication of gonorrhea.

Question 3 of 5

The rate of obesity in the United States has reached epidemic proportions. Morbidity and mortality for both the mother and baby are increased in these circumstances. The nurse caring for the patient with an elevated BMI should be cognizant of these potential complications and plan care accordingly. Significant risks include (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A: Breech presentation. Obesity can lead to a larger fetus, increasing the risk of breech presentation. The rationale is that excess fat can hinder the baby's ability to turn head down. Other choices are incorrect because: B: Ectopic pregnancy is not related to obesity, C: Birth defects can be influenced by maternal health but are not directly linked to obesity, and D: Venous thromboembolism is more associated with immobility and hypercoagulable states rather than obesity.

Question 4 of 5

A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patients care plan addresses the risk of hemorrhage. How should the nurse best monitor the patients postoperative blood loss?

Correct Answer: B

Rationale: The correct answer is B: Count and inspect each perineal pad that the patient uses. This method directly measures postoperative blood loss and allows for accurate monitoring. It provides quantitative data to assess the severity of hemorrhage. A: Having the patient void and have bowel movements using a commode rather than toilet does not directly measure blood loss and may not provide accurate monitoring. C: Swabbing the patient's perineum for the presence of blood is not as accurate as directly counting and inspecting perineal pads. D: Leaving the patient's perineum open to air does not provide a method for quantifying blood loss and may not be as reliable as inspecting perineal pads.

Question 5 of 5

A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond?

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.

Similar Questions

A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond?
In providing prenatal care to a pregnant patient, what does the nurse teach the expectant mother?
The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?
A patients decline in respiratory and renal function has been attributed to Goodpasture syndrome, which is a type II hypersensitivity reaction. What pathologic process underlies the patients health problem?
A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding?

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