test bank foundations of nursing

Correct Answer: C

Rationale: Rationale: 1. Erythema of nipple/areola in one breast can be a sign of Paget's disease, a rare form of breast cancer. 2. Paget's disease may also present with itching, tingling, or a burning sensation in the affected area. 3. Referring the patient promptly is crucial for early detection and appropriate management. 4. Peau d'orange (A) is a sign of advanced breast cancer, not typically presenting with erythema alone. 5. Nipple inversion (B) may be benign or related to other conditions, not typically presenting with erythema. 6. Acute mastitis (D) presents with breast pain, warmth, swelling, and fever, but not typically with isolated erythema of the nipple/areola.

Correct Answer: C

Rationale: The correct answer is C: Avoid lifting objects heavier than 10 pounds. This recommendation is crucial post-mastectomy as it helps prevent lymphedema and promotes healing without causing strain on the surgical site. Lifting heavy objects can lead to complications such as lymphedema or disruption of the healing process. Options A, B, and D are incorrect as avoiding exercise of the arm for 2 months may lead to stiffness and reduced range of motion, keeping cuticles clipped neatly does not directly affect rehabilitation, and using a sling is not necessary unless specifically advised by the healthcare provider.

Correct Answer: A

Rationale: The correct answer is A: Provide emotional support to the patient and her family. This is the priority as the patient has received devastating news and needs immediate support. Emotional support can help the patient cope with the diagnosis, express feelings, and make decisions. B: Implementing distraction techniques may not address the patient's emotional needs in this critical situation. C: Offering to inform the family of the diagnosis is important but not the priority at this moment. D: Teaching about maintaining a positive attitude may not be appropriate as the patient is facing a terminal illness.

Correct Answer: C

Rationale: The correct answer is C: Sensorineural hearing loss. This type of hearing loss is caused by damage to the inner ear or auditory nerve (cranial nerve VIII). Exostoses (A) are bony growths in the ear canal, not related to cranial nerve VIII. Otalgia (B) refers to ear pain, not hearing loss. Presbycusis (D) is age-related hearing loss, not specifically related to damage of the end organ for hearing or cranial nerve VIII. Therefore, C is the most appropriate term to describe the given condition.

Correct Answer: C

Rationale: The correct answer is C because putting on a second pair of gloves over soiled gloves during a procedure violates standard precautions by increasing contamination risk. Here's the rationale: 1. Standard precautions require removing soiled gloves before putting on new ones to prevent cross-contamination. 2. Wearing multiple gloves increases the risk of tearing and exposure to pathogens. 3. This behavior shows a lack of understanding of proper infection control practices. Summary of other choices: A: Wearing face protection, gloves, and a gown when irrigating a wound is a correct practice. B: Washing hands with waterless antiseptic after removing soiled gloves is correct. D: Placing a used needle and syringe in a puncture-resistant container without capping the needle is incorrect, but not as severe as choice C.