foundations of nursing practice questions

Correct Answer: C

Rationale: The correct answer is C: Encourage the patient to keep his or her feeding area clean. This is the most appropriate independent nursing action as it promotes hygiene and reduces the risk of infection. Keeping the feeding area clean is essential in preventing complications in a patient with malnutrition. Rationales for why the other choices are incorrect: A: Firmly redirect the patient's head when feeding - This is incorrect because forceful redirection can cause distress and discomfort to the patient, potentially leading to aspiration or choking. B: Administer phenothiazines after each meal as ordered - This is incorrect as phenothiazines are not typically used for malnutrition treatment and should not be administered without a specific indication. D: Apply deep, gentle pressure around the patient's mouth to aid swallowing - This is incorrect because applying pressure around the mouth can pose a choking hazard and should not be done without proper assessment and intervention by a speech therapist or swallowing specialist.

Correct Answer: D

Rationale: The correct answer is D: Surgical intervention. Cataracts are a clouding of the lens in the eye, which can lead to vision impairment. Surgery is the most common and effective treatment for cataracts, involving the removal of the cloudy lens and replacement with an artificial one. Antioxidant supplements (Choice A) may help prevent cataracts but are not a treatment for existing ones. Eyeglasses or magnifying lenses (Choice B) can help with vision correction but do not address the cataracts themselves. Corticosteroid eye drops (Choice C) are used for treating inflammation in the eye, not cataracts. Therefore, surgical intervention is the most appropriate treatment option for age-related cataracts.

Correct Answer: A

Rationale: The correct answer is A: Anaphylactic reaction after a bee sting. Type I hypersensitivity reactions involve an immediate response triggered by exposure to an allergen, leading to the release of histamine and other inflammatory mediators. In this case, a bee sting would introduce an allergen, causing a rapid and severe systemic reaction, known as anaphylaxis. B: Skin reaction resulting from adhesive tape is an example of a Type IV hypersensitivity reaction, mediated by T cells, not IgE antibodies as in Type I reactions. C: Myasthenia gravis is an autoimmune disorder involving antibodies attacking acetylcholine receptors, not a Type I hypersensitivity reaction. D: Rheumatoid arthritis is an autoimmune disorder involving immune complexes and inflammatory responses, not a Type I hypersensitivity reaction.

Correct Answer: C

Rationale: The correct answer is C: Women over age 40. Annual clinical breast examinations are recommended for this population group because they have an increased risk of developing breast cancer compared to younger age groups. Regular screenings starting at age 40 can help in early detection and improve survival rates. A: Women over age 21 - This age group is generally recommended to start clinical breast examinations every 1-3 years, not necessarily annually. B: Women over age 25 - While it's important to be vigilant about breast health, the risk of breast cancer increases with age, making annual exams more crucial for older women. D: All post-pubescent females with a family history of breast cancer - While family history is a risk factor, the recommendation for annual clinical breast examinations typically begins at age 40, regardless of family history.

Correct Answer: B

Rationale: The correct answer is B: Protect the patient's airway. In anaphylaxis, airway compromise can lead to respiratory distress and even respiratory arrest. The priority is to ensure the patient has a patent airway to maintain oxygenation. This can be achieved through interventions such as positioning, oxygen therapy, and potentially intubation if needed. Monitoring the patient's level of consciousness (A) is important but secondary to ensuring airway patency. Providing psychosocial support (C) is not the immediate priority in anaphylaxis. Administering medications (D) is also important but only after ensuring the airway is protected.