foundations of nursing practice questions

Correct Answer: D

Rationale: The correct answer is D, combining multiple objective measures with subjective measures. This approach provides a comprehensive assessment of the patient's nutritional status by incorporating both quantitative data (objective measures) such as weight, BMI, and laboratory values, as well as qualitative information (subjective measures) like dietary history and appetite changes. By combining these measures, the nurse can obtain a more holistic view of the patient's nutritional status, allowing for better identification of nutritional deficiencies or excesses. This method enhances the accuracy and reliability of the assessment compared to relying solely on one type of measure. Choice A is incorrect because nutritional assessment is crucial even in the presence of chronic disease to address potential malnutrition risks. Choice B is incorrect as the Mini Nutritional Assessment is not intended for pediatric patients but for adults. Choice C is incorrect as using a single tool may not capture the full complexity of the patient's nutritional status.

Correct Answer: C

Rationale: The correct answer is C: The patient has diabetes. Diabetes can lead to diabetic retinopathy, a common cause of low vision. By knowing the patient's medical history, the nurse can recommend appropriate low vision aids and refer the patient to an ophthalmologist for further evaluation and management. Incorrect choices: A: The patient uses OTC NSAIDs - NSAIDs are not relevant to managing low vision. B: The patient has a history of stroke - A history of stroke is not directly related to low vision. D: The patient has Asian ancestry - Ancestry is not a factor in managing low vision.

Correct Answer: C

Rationale: The correct answer is C: Assist to a standing position. This action helps utilize gravity to aid in emptying the bladder and may help the patient void without the need for invasive measures like catheterization or medications. It is a non-invasive and natural approach to promote urination. Limiting fluid intake (A) could worsen the situation by concentrating urine and worsening retention. Inserting a urinary catheter (B) should be considered only if other measures fail. Asking for a diuretic medication (D) does not address the immediate need for bladder emptying and may not be necessary if the patient can void naturally.

Correct Answer: A

Rationale: The correct answer is A: When the patient is resting. This is because the tremor associated with Parkinson's disease is most noticeable when the patient is at rest due to the characteristic "resting tremor" seen in this condition. The tremor tends to lessen or disappear with purposeful movements or activities, making it more difficult to assess during ambulation, meal preparation, or occupational therapy. By observing the patient at rest, the nurse can accurately assess the presence and severity of the tremor, which is a key diagnostic feature of Parkinson's disease. Other answer choices are incorrect because they do not provide the optimal condition for assessing the tremor associated with Parkinson's disease.

Correct Answer: D

Rationale: The correct answer is D: Immunoglobulin E. The atopic response in allergies is mainly mediated by IgE antibodies. IgE binds to allergens and triggers the release of histamine and other chemicals that cause allergic symptoms. IgA is mainly found in mucosal areas, IgM is involved in early immune responses, and IgG is important for long-term immunity. IgE is specifically associated with allergic reactions due to its role in sensitizing mast cells and basophils to allergens.