foundations of nursing practice questions

Correct Answer: A

Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely

Correct Answer: D

Rationale: The correct answer is D because it provides an accurate and comprehensive response to the pregnant patient's question about the risk of her baby being born with HIV. Here's the step-by-step rationale: 1. Option D acknowledges the possibility of the baby contracting HIV at different stages: before, during, or after delivery. This covers all potential scenarios and educates the patient about the risks. 2. By mentioning the different possible transmission times, the nurse highlights the importance of proper prenatal care, delivery planning, and postnatal care to minimize the risk of HIV transmission to the baby. 3. This response empowers the patient with knowledge about the potential risks and emphasizes the importance of seeking appropriate medical interventions to prevent mother-to-child transmission of HIV. 4. In contrast, options A, B, and C provide less informative or inaccurate responses that do not address the patient's concerns adequately, making them incorrect choices. In summary, option D is the best response as it educates the patient about the risks of HIV transmission

Correct Answer: B

Rationale: The correct answer is B: Jejunostomy tube. This tube is chosen because the patient has a history of aspiration pneumonia, which puts them at risk for aspiration if feeds are administered into the stomach. By administering feeds through a jejunostomy tube, the risk of aspiration pneumonia is minimized as the feed bypasses the stomach. Nasogastric tube (A) and Nasointestinal tube (C) would still deliver feeds to the stomach, increasing the risk of aspiration. PEG tube (D) is also not ideal as it delivers feeds directly to the stomach, which is not recommended for patients at risk for aspiration.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Hearing-impaired patient is likely unable to hear during an MRI due to loud noises. 2. Nurse needs to use alternative communication methods like writing or gestures. 3. Sign language interpreter may not be necessary for an MRI. 4. Lip reading may be challenging due to the noisy MRI environment. 5. Interaction should be adapted to accommodate the patient's communication needs.

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.