foundations of nursing test bank

foundations of nursing test bank Related

Review foundations of nursing test bank related questions and content

A 22-year-old male is being discharged home after surgery for testicular cancer. The patient is scheduled to begin chemotherapy in 2 weeks. The patient tells the nurse that he doesnt think he can take weeks or months of chemotherapy, stating that he has researched the adverse effects online. What is the most appropriate nursing action for this patient at this time?

  • A. Provide empathy and encouragement in an effort to foster a positive outlook.
  • B. Tell the patient it is his decision whether to accept or reject chemotherapy.
  • C. Report the patients statement to members of his support system.
  • D. Refer the patient to social work.
Correct Answer: A

Rationale: Correct Answer: A. Provide empathy and encouragement in an effort to foster a positive outlook.

Rationale:
1. Empathy and encouragement are essential in establishing rapport and trust with the patient.
2. By fostering a positive outlook, the nurse can help alleviate the patient's anxiety and fears.
3. Encouraging a positive mindset can improve the patient's adherence to treatment.
4. It is important to address the patient's concerns and provide support rather than dismissing them.

Summary:
B: Telling the patient it is his decision may not address his emotional needs and could lead to further distress.
C: Reporting the patient's statement to his support system may breach confidentiality and undermine trust.
D: Referring the patient to social work may be premature without first addressing the patient's emotional concerns directly.

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An 86-year-old patient is experiencing uncontrollableleakage of urine with a strong desire to void and even leaks on the way to the toilet. Whichprioritynursing diagnosiswill the nurse include in the patient’s plan of care?

  • A. Functional urinary incontinence
  • B. Urge urinary incontinence
  • C. Impaired skin integrity
  • D. Urinary retention
Correct Answer: B

Rationale: Correct Answer: B - Urge urinary incontinence

Rationale:
1. The patient's symptoms of strong desire to void and leakage on the way to the toilet indicate urge urinary incontinence.
2. Urge urinary incontinence is characterized by a sudden, strong need to urinate with involuntary leakage.

Incorrect Choices:
A: Functional urinary incontinence - This type is due to factors such as cognitive or physical impairment, not a strong urge to void.
C: Impaired skin integrity - While important, this is a potential consequence of urinary incontinence, not the priority nursing diagnosis.
D: Urinary retention - This would present with the inability to empty the bladder, not symptoms of frequent urge to void and leakage.

A hospice nurse is caring for a 22-year-old with a terminal diagnosis of leukemia. When updating this patients plan of nursing care, what should the nurse prioritize?

  • A. Interventions aimed at maximizing quantity of life
  • B. Providing financial advice to pay for care
  • C. Providing realistic emotional preparation for death
  • D. Making suggestions to maximize family social interactions after the patients death
Correct Answer: C

Rationale: The correct answer is C because providing realistic emotional preparation for death is a priority in caring for a patient with a terminal illness like leukemia. This helps the patient and their loved ones cope with the impending loss and make the most of the time left. Option A focuses solely on prolonging life, which may not align with the patient's wishes. Option B, providing financial advice, is important but not the top priority in this situation. Option D, maximizing family social interactions after the patient's death, is not immediate and does not address the patient's emotional needs.

A nursing student is learning how to perform sexual assessments using the PLISSIT model. According to this model, the student should begin an assessment by doing which of the following?

  • A. Briefly teaching the patient about normal sexual physiology
  • B. Assuring the patient that what he says will be confidential
  • C. Asking the patient if he is willing to discuss sexual functioning
  • D. Ensuring patient privacy
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.

A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding?

  • A. This is a normal aging process of the eye.
  • B. Glasses will minimize this phenomenon.
  • C. The patient may be exhibiting signs of glaucoma.
  • D. This may be a result of weakened ciliary muscles.
Correct Answer: A

Rationale: The correct answer is A because floaters are commonly caused by age-related changes in the vitreous humor of the eye, such as the formation of tiny fibers or clumps. These floaters are typically harmless and not a cause for concern. Choice B is incorrect because glasses do not affect floaters in the eye. Choice C is incorrect because floaters are not a primary symptom of glaucoma. Choice D is incorrect because weakened ciliary muscles are not typically associated with floaters. Therefore, the most appropriate interpretation is that seeing floaters is a normal aging process of the eye.

A patient with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate

  • A. gastrointestinal upset.
  • B. effects of magnesium sulfate.
  • C. anxiety caused by hospitalization.
  • D. worsening disease and impending convulsion.
Correct Answer: D

Rationale: The correct answer is D because the patient's symptoms of pounding headache, visual changes, and epigastric pain are classic signs of worsening preeclampsia, indicating a significant increase in blood pressure and potential progression to eclampsia (seizures). Immediate medical intervention is crucial to prevent complications.
A: Gastrointestinal upset does not explain the combination of symptoms presented.
B: Magnesium sulfate is used to prevent seizures in preeclampsia but does not cause these specific symptoms.
C: Anxiety does not typically present with the specific physical symptoms mentioned.

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