test bank foundations of nursing

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.

Correct Answer: B

Rationale: The correct answer is B: Compensating for vision loss for the next several weeks. This is the priority subject for discharge education because vision loss is a common outcome post vitreoretinal procedure. The patient needs to understand how to adapt to this temporary impairment, such as using assistive devices and modifying their environment. A: Risk factors for postoperative CMV is not the priority as it is not a common concern in this situation. C: Non-pharmacologic pain management is important but not the priority compared to vision loss. D: Signs and symptoms of increased intraocular pressure are important but not as crucial as managing vision loss.

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.

Correct Answer: A

Rationale: The correct answer is A: Provide emotional support to the patient and her family. This is the priority as the patient has received devastating news and needs immediate support. Emotional support can help the patient cope with the diagnosis, express feelings, and make decisions. B: Implementing distraction techniques may not address the patient's emotional needs in this critical situation. C: Offering to inform the family of the diagnosis is important but not the priority at this moment. D: Teaching about maintaining a positive attitude may not be appropriate as the patient is facing a terminal illness.

Correct Answer: B

Rationale: The correct answer is B (2, 4, 1, 3, 5) because it follows the correct sequential order for initiating feeding. First, you need to prepare the food (2), then set up the feeding area (4), followed by inviting the person to eat (1), serving the food (3), and finally allowing them to eat (5). The other choices do not adhere to the logical sequence required for initiating feeding. Choice A and D have incorrect sequences of steps, while Choice C has steps 1 and 4 switched, which disrupts the proper order of initiating feeding.