foundations of nursing practice questions

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: 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: A

Rationale: The correct answer is A because acknowledging the patient's fear validates their emotions, builds trust, and shows empathy. This can help the patient feel understood and supported during a vulnerable time. Choice B is incorrect because discussing support groups may not address the patient's immediate emotional needs. Choice C is incorrect because assessing stress management skills may not be the priority at this moment when the patient is visibly tense. Choice D is incorrect because documenting a nursing diagnosis should come after addressing the patient's immediate emotional state.

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: A

Rationale: The correct answer is A: Pelvic floor exercises. Pelvic floor exercises help strengthen the muscles that control urination, promoting continence. These exercises can improve bladder control and reduce urinary incontinence post-prostatectomy. Intermittent urinary catheterization (B) may lead to increased risk of infection. Reduced physical activity (C) can weaken pelvic floor muscles, worsening incontinence. Active range of motion exercises (D) do not directly address urinary incontinence.