foundation of nursing questions and answers

Correct Answer: C

Rationale: The correct answer is C: Occlude the puncta after applying the medication. By occluding the puncta after applying the eye drops, the nurse can prevent the medication from draining into the nasolacrimal duct and being absorbed systemically. This is important to ensure that the medication remains in the eye and exerts its intended local effect. Choice A (Ensure that the patient is well hydrated at all times) is incorrect because hydration status does not directly prevent absorption through the nasolacrimal duct. Choice B (Encourage self-administration of eye drops) is incorrect as the method of administration does not prevent absorption through the nasolacrimal duct. Choice D (Position the patient supine before administering eye drops) is incorrect as it does not address the specific issue of preventing absorption through the nasolacrimal duct.

Correct Answer: B

Rationale: The correct answer is B: Pink. In a healthy ear, the tympanic membrane should appear pink due to the rich blood supply. This color indicates good vascularization and normal functioning of the ear. Yellowish-white (choice A), gray (choice C), and bluish-white (choice D) are incorrect because they do not reflect the normal color of a healthy tympanic membrane. Yellowish-white may indicate fluid behind the eardrum, gray may suggest infection or inflammation, and bluish-white could indicate poor blood flow or trauma. Therefore, the pink color of the tympanic membrane is the most appropriate and indicative of a healthy ear in this case.

Correct Answer: C

Rationale: The correct answer is C: Impaired verbal communication. In ALS, motor neurons deteriorate leading to muscle weakness and atrophy, including those involved in speech production. This results in impaired verbal communication. Chronic confusion (A) is not a common manifestation of ALS. Impaired urinary elimination (B) and bowel incontinence (D) are not typically associated with ALS, as it primarily affects motor neurons, not autonomic functions.

Correct Answer: A

Rationale: The correct answer is A: Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces? This question is important because electronystagmography involves the patient being placed in a confined space with sensors attached to monitor eye movements. Claustrophobia or anxiety can significantly impact the patient's ability to tolerate the test, affecting its accuracy. Choice B: Do you currently take any tranquilizers or stimulants on a regular basis? While relevant in some cases, it is not as crucial as ensuring the patient can tolerate the test environment. Choice C: Do you have a history of falls or problems with loss of balance? While relevant to Mnire's disease, it is not directly related to the preparation for electronystagmography. Choice D: Do you have a history of either high or low blood pressure? While monitoring blood pressure is important for some procedures, it is not a primary concern for electronystagmography.

Correct Answer: D

Rationale: The correct answer is D: Obtain a stool culture to identify possible pathogens. This is the most appropriate nursing intervention because chronic diarrhea in a patient with AIDS can be caused by various pathogens such as parasites, bacteria, or viruses. By obtaining a stool culture, the healthcare team can identify the specific pathogen responsible for the diarrhea and initiate targeted treatment. A: Positioning the patient in the high Fowler's position is not directly related to addressing the underlying cause of chronic diarrhea in this patient. B: Temporarily eliminating animal protein from the patient's diet may not be necessary or effective in treating chronic diarrhea without knowing the specific cause identified through stool culture. C: Making sure the patient eats raw fruit is not recommended as raw fruits can sometimes worsen diarrhea due to their high fiber content and potential for carrying pathogens. In summary, obtaining a stool culture is the most appropriate intervention as it helps identify the specific pathogen causing the diarrhea, while the other options do not directly address the underlying cause.