test bank foundations of nursing

Correct Answer: B

Rationale: The correct answer is B because Rh incompatibility occurs when an Rh-negative mother carries an Rh-positive fetus. If fetal blood enters the mother's circulation during pregnancy or childbirth, the mother's immune system can produce antibodies against Rh-positive red blood cells, leading to potential harm to future pregnancies. Choices A, C, and D are incorrect because Rh incompatibility does not occur when the fetus is Rh-negative, the father is Rh-positive, or both the father and fetus are Rh-negative.

Correct Answer: A

Rationale: The correct answer is A: Disturbed body image. Enucleation can have a significant impact on a patient's self-image and self-esteem. By addressing this nursing diagnosis, the nurse can help the patient cope with the changes in their physical appearance and support them in adjusting to wearing a prosthesis. Summary: - Choice B (Chronic pain) is incorrect because enucleation may cause acute pain initially, but chronic pain is not a common concern post-enucleation. - Choice C (Ineffective protection) is incorrect because enucleation does not necessarily affect the eye's protection mechanism. - Choice D (Unilateral neglect) is incorrect as it refers to a neurological condition unrelated to the patient's situation post-enucleation.

Correct Answer: D

Rationale: The correct answer is D: According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy. 1. Breast conservation surgery followed by radiation is a standard treatment option for early-stage breast cancer. 2. Studies have shown that breast conservation surgery combined with radiation therapy is equally effective in terms of long-term survival rates compared to mastectomy. 3. Current guidelines recommend considering breast conservation surgery as a viable option for patients with early-stage breast cancer. 4. Modified radical mastectomy is not necessarily needed to ensure complete removal of cancer, as breast conservation surgery followed by radiation can achieve the same goal. 5. Therefore, the nurse should reassure the patient's husband that the recommended treatment plan is based on current guidelines and is as effective as a modified radical mastectomy.

Correct Answer: B

Rationale: The correct answer is B: Sleep on a firm mattress. A firm mattress helps maintain proper spinal alignment, reducing pressure on the cervical spine. This promotes healing and prevents worsening of symptoms. A: Performing active ROM exercises may exacerbate symptoms and worsen the condition. C: Applying cool compresses may provide temporary relief but does not address the underlying issue of spinal alignment. D: Wearing a cervical collar for extended periods can weaken neck muscles and hinder natural healing processes. In summary, sleeping on a firm mattress is the most appropriate conservative measure as it supports proper spinal alignment.

Correct Answer: A

Rationale: The correct answer is A: A verbal report. This is because exchanging information verbally between nurses allows for real-time communication, ensuring important details are accurately conveyed. Electronic record entry (B) involves documenting information in the patient's record but does not involve direct communication. Referral (C) refers to transferring the patient's care to another healthcare provider. Acuity rating (D) is a tool used to determine the severity of a patient's condition and does not involve exchanging information between nurses.