test bank foundations of nursing

Questions 102

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test bank foundations of nursing Questions

Question 1 of 5

The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient�s skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?

Correct Answer: A

Rationale: The correct answer is A: Drink more water to prevent further dehydration. Given the patient's fair skin turgor, fatigue, weakness, warm and dry skin, elevated pulse rate, and slightly elevated urinary sodium level, these are signs of dehydration. Increasing water intake would help improve the patient's hydration status. Other choices are incorrect because B (calorie-dense fluids) does not address the dehydration issue, C (milk and dairy products) does not directly address the symptoms presented, and D (grapefruit juice) is not essential for hydration in this case.

Question 2 of 5

A nurse is planning the care of a patient with AIDS who is admitted to the unit withPneumocystis pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?

Correct Answer: A

Rationale: The correct answer is A: Ineffective Airway Clearance. In a patient with AIDS and PCP, maintaining clear airways is crucial to prevent respiratory distress and hypoxia. Pneumocystis pneumonia can cause thick secretions and mucus plugging, leading to difficulty breathing. Ensuring effective airway clearance is a priority to optimize oxygenation and prevent respiratory complications. Impaired oral mucous membranes (B) and imbalanced nutrition (C) are important considerations but not as immediate as airway clearance. Activity intolerance (D) may be a concern for the patient but ensuring adequate oxygenation takes precedence.

Question 3 of 5

Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely cause this abnormality?

Correct Answer: A

Rationale: The correct answer is A: Rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, which includes bilateral cataracts as a characteristic feature. Rubella virus can cross the placenta and affect the developing fetus. Cytomegalovirus (CMV) can also cause congenital cataracts, but rubella is more commonly associated with this abnormality. Syphilis can cause other congenital abnormalities but not bilateral cataracts. HIV does not typically lead to bilateral cataracts in newborns.

Question 4 of 5

A nurse is teaching the staff about informatics.Which information from the staff indicates the nurse needs to follow up?

Correct Answer: C

Rationale: The correct answer is C. Computer competency does not equate to informatics competency. Informatics involves more than just basic computer skills; it encompasses the ability to use technology to manage and analyze data for improved healthcare outcomes. A: This is a correct statement about informatics proficiency. B: This is also a correct statement about the skills needed for informatics. D: This is a true statement about nursing informatics being a recognized specialty, but it does not indicate a need for follow-up. In summary, choice C is incorrect as it oversimplifies the concept of informatics, while choices A, B, and D provide accurate information related to informatics.

Question 5 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.

Similar Questions

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?
A patient with Parkinsons disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond?
A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and complementary therapies. How should the nurse best respond?
A nurse is reviewing urinary laboratory results.Which finding will cause the nurse to follow up?
The nurse has observed that an older adult patient with a diagnosis of end-stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond?

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