foundations of nursing practice questions

Correct Answer: A

Rationale: Step-by-step rationale for why A is correct: 1. Retinal detachment causes traction on the retina. 2. Traction on the retina can stimulate photoreceptors. 3. Stimulation of photoreceptors can lead to perception of flashing lights. 4. Therefore, the characteristic symptom of retinal detachment is flashing lights in the visual field. Summary: B: Sudden eye pain is not a characteristic symptom of retinal detachment. C: Loss of color vision is not typically associated with retinal detachment. D: Colored halos around lights are more indicative of conditions like glaucoma or corneal edema, not retinal detachment.

Correct Answer: A

Rationale: The correct answer is A: Complicated grief and mourning. This is characterized by a sense of emotional numbness and feeling hollow inside, which the patient's spouse is experiencing after the patient's death. Complicated grief involves intense and prolonged mourning that may interfere with daily functioning. Other choices are incorrect because: B: Uncomplicated grief and mourning typically involves a range of emotions, including sadness and sorrow, but not the profound numbness and emptiness described. C: Depression stage of dying refers to a stage in the Kubler-Ross model, but the patient's spouse is not the one dying, so this does not apply. D: Acceptance stage of dying involves coming to terms with one's impending death, not the aftermath of losing a loved one to sepsis.

Correct Answer: C

Rationale: The correct answer is C because documenting medication administration is critical for patient safety and continuity of care. By documenting the pain medication received, the nurse ensures accurate medication tracking and prevents errors. Choice A is incorrect as it lacks specific, objective information. Choice B is irrelevant to patient care. Choice D is inappropriate and violates patient confidentiality.

Correct Answer: B

Rationale: The correct answer is B: Report to the emergency department or employee health department. 1. Immediate action is crucial after exposure to HIV-positive blood. 2. Reporting to the emergency department or employee health department ensures prompt evaluation and appropriate management. 3. The supervisor should also be informed to initiate the necessary protocols. 4. The other choices are incorrect: - A: Chlorhexidine may not be sufficient for post-exposure prophylaxis. - C: Hydrocolloid dressing is not appropriate for managing needlestick injuries. - D: Following up with the primary care provider may cause delays in receiving timely post-exposure prophylaxis.

Correct Answer: B

Rationale: The correct answer is B: Impaired wound healing. Radiation therapy can lead to damage to the skin and blood vessels, affecting wound healing. The nurse should prioritize assessing the patient's skin integrity and any signs of impaired wound healing to prevent complications post-surgery. A: Cognitive deficits - While radiation therapy can impact cognitive function in some cases, it is not the most immediate concern related to surgery post-radiation therapy. C: Cardiac tamponade - Although radiation therapy can increase the risk of heart-related issues, such as pericarditis, cardiac tamponade is a rare and acute complication that is not the most likely immediate concern post-radiation therapy. D: Tumor lysis syndrome - This syndrome is more commonly seen in patients undergoing chemotherapy rather than radiation therapy. It is not typically a concern immediately post-radiation therapy.