test bank foundations of nursing

Questions 102

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test bank foundations of nursing Questions

Question 1 of 5

The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?

Correct Answer: C

Rationale: The correct term for the involuntary, rhythmic eye movements seen in the patient with multiple sclerosis is nystagmus. Nystagmus is a condition characterized by repetitive, uncontrolled eye movements that can be horizontal, vertical, or rotary. In multiple sclerosis, nystagmus can occur due to damage to the nerves that control eye movement. Vertigo (choice A) is a sensation of spinning or dizziness, not related to eye movements. Tinnitus (choice B) is a perception of noise or ringing in the ears. Astigmatism (choice D) is a refractive error of the eye, not related to involuntary eye movements.

Question 2 of 5

During a recent visit to the clinic a woman presents with erythema of the nipple and areola on the right breast. She states this started several weeks ago and she was fearful of what would be found. The nurse should promptly refer the patient to her primary care provider because the patients signs and symptoms are suggestive of what health problem?

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.

Question 3 of 5

A labor and birth nurse receives a call from the laboratory regarding a preeclamptic patient receiving an IV infusion of magnesium sulfate. The laboratory technician reports that the patient�s magnesium level is 6 mg/dL. What is the nurse�s priority action?

Correct Answer: A

Rationale: The correct answer is A: Stop the infusion of magnesium. A magnesium level of 6 mg/dL is above the therapeutic range (4-7 mg/dL) for preeclamptic patients receiving magnesium sulfate. Continuing the infusion can lead to magnesium toxicity, causing respiratory depression, cardiac arrest, and neuromuscular blockade. Stopping the infusion is crucial to prevent further complications. Assessing the patient's respiratory rate (B) and deep tendon reflexes (C) are important, but stopping the infusion takes priority to prevent harm. Notifying the health care provider (D) is important but may delay immediate action to address the high magnesium level.

Question 4 of 5

The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinsons disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care?

Correct Answer: D

Rationale: The correct answer is D: Supporting the patients and family's values and choices. In this scenario, the nurse should prioritize respecting the patient's preference to receive care at home and involving the family in decision-making. This approach promotes patient autonomy, dignity, and quality of life. Choice A is incorrect as aggressively fighting the disease process may not align with the patient's wishes for comfort-focused care in hospice. Choice B is incorrect because moving the patient to a long-term care facility goes against the patient's preference to receive care at home. Choice C is not the priority as including the children in planning care is important but not as crucial as respecting the patient's wishes directly.

Question 5 of 5

An oncology nurse is caring for a patient who has developed erythema following radiation therapy. What should the nurse instruct the patient to do?

Correct Answer: C

Rationale: The correct answer is C: Apply petroleum jelly to the affected area. This is because petroleum jelly helps to soothe and protect the skin, reducing dryness and irritation caused by radiation therapy. Ice (A) can further damage the skin, shaving (B) can increase the risk of infection, and soap (D) can be too harsh on the sensitive skin. Therefore, instructing the patient to apply petroleum jelly is the most appropriate recommendation to promote skin healing and comfort.

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