foundations of nursing test bank

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: C

Rationale: Rationale: Choice C is correct because understanding the illness from the patient's perspective helps nurses provide individualized care. By empathizing with the patient's experience, nurses can tailor support to meet their specific needs. Describing personal experiences (A) may not be appropriate as it shifts the focus from the patient. Encouraging fighting for a cure (B) may not align with the patient's wishes for quality of life. Assisting with life review (D) can be beneficial but may not be a priority for all patients. Providing interventions for end-of-life closure (E) is important, but understanding the illness from the patient's perspective (C) forms the foundation for effective support.

Correct Answer: C

Rationale: The nurse will use the history of angina for "B" when using SBAR because it provides relevant background information about the patient's cardiac condition. This helps the nurse understand the context of the current situation and make appropriate decisions. Pulse rate of 108 (choice B) is a specific vital sign and not an appropriate choice for "B" in SBAR. Having chest pain (choice A) is important but does not provide the necessary background information like the history of angina does. Oxygen being needed (choice D) is a current intervention and not relevant for "B" in SBAR, which focuses on providing background information.

Correct Answer: C

Rationale: The correct answer is C: Assessment of nutritional status. Cachexia is a complex metabolic syndrome characterized by weight loss, muscle wasting, and weakness commonly seen in cancer patients. Assessing the patient's nutritional status is crucial to address the underlying causes of cachexia and to develop an appropriate management plan. This assessment includes evaluating dietary intake, weight changes, body composition, and nutritional deficiencies. Choice A: Assessment of peripheral nervous function is not the priority in this case as cachexia is primarily related to metabolic and nutritional issues rather than peripheral nervous system dysfunction. Choice B: Assessment of cranial nerve function is also not the priority since cachexia is not directly associated with cranial nerve dysfunction. Choice D: Assessment of respiratory status may be important in general patient care, but in this case, addressing the underlying nutritional issues that are contributing to cachexia should be the priority.

Correct Answer: C

Rationale: The correct answer is C because primary brain tumors originate from cells within the brain itself. These tumors develop from abnormal growth of brain cells. Choice A is incorrect as primary brain tumors do not come from outside the central nervous system (CNS). Choice B is incorrect as primary brain tumors do not typically start in glands. Choice D is incorrect as primary brain tumors do not arise from nerve tissue elsewhere in the body. In summary, the nurse should explain to the patient that the tumor originated from cells within his brain to provide accurate information about the nature of primary brain tumors.