foundations of nursing test bank

Correct Answer: D

Rationale: Correct Answer: D Rationale: - Giving a change-of-shift report to the oncoming nurse about the patient is an appropriate action that maintains confidentiality by only sharing necessary patient information with authorized healthcare professionals. - A: Writing the patient�s room number and date of birth on a paper for school is a breach of confidentiality as it exposes sensitive patient information to unauthorized individuals. - B: Printing/copying material from the patient�s health record for a graded care plan is also a breach of confidentiality as it involves sharing patient information without proper authorization. - C: Reviewing assigned patient�s record and another unassigned patient�s record is a violation of HIPAA as it involves accessing patient information that is not necessary for the nurse's duties, risking unauthorized disclosure.

Correct Answer: C

Rationale: The correct answer is C because the severity of an anaphylactic reaction can vary greatly from one episode to another in the same patient. Anaphylactic reactions are unpredictable and can be influenced by various factors such as the amount of allergen exposure, individual immune response, underlying health conditions, and concurrent medications. Therefore, it is not possible to reliably gauge the severity of a patient's anaphylactic reaction even if it has occurred repeatedly in the past. Choice A is incorrect because the onset of symptoms alone is not a reliable predictor of the severity of the reaction. Choice B is incorrect as well because there is no set formula to predict that the reaction will be one-third more severe than the patient's last reaction. Choice D is incorrect because stating that the reaction will generally be slightly less severe than the last reaction is also not accurate or supported by evidence.

Correct Answer: C

Rationale: Step 1: After mastoid surgery, patients may experience pain and dizziness, hence addressing the safe use of analgesics and antivertiginous agents is crucial for symptom management. Step 2: Analgesics help in managing post-operative pain, while antivertiginous agents help control dizziness, reducing the risk of falls. Step 3: Educating the patient on safe use ensures proper pain and symptom management, preventing complications. Step 4: Other choices are incorrect as they do not directly address immediate post-operative care needs such as pain and dizziness management.

Correct Answer: A

Rationale: Rationale for Correct Answer A: Applying a protective eye shield at night is crucial for a patient with Bell's palsy to prevent corneal abrasions due to incomplete eyelid closure. This action helps protect the eye from dryness and injury, which can occur due to decreased blinking and moisture. It is essential to maintain eye health and prevent complications. Summary of Incorrect Choices: B: Chewing on the affected side does not prevent unilateral neglect in Bell's palsy. Instead, encouraging balanced chewing and facial exercises would be more beneficial. C: Avoiding the use of analgesics is not necessary for Bell's palsy management unless contraindicated, as pain management may be required for associated symptoms. D: Avoiding brushing the teeth is not recommended. Good oral hygiene is important for overall health, including maintaining oral health during Bell's palsy.

Correct Answer: D

Rationale: The correct answer is D: Ensuring patient privacy. In the PLISSIT model, ensuring patient privacy is crucial as it creates a safe and confidential environment for discussing sensitive topics like sexual health. This step helps build trust and allows the patient to feel comfortable sharing intimate details. Briefly teaching about normal sexual physiology (A) may come later in the assessment process. Assuring confidentiality (B) is important but doesn't address the immediate need for privacy. Asking if the patient is willing to discuss sexual functioning (C) assumes patient readiness without first establishing a private setting.