foundation of nursing questions

foundation of nursing questions Related

Review foundation of nursing questions related questions and content

A 62-year-old woman diagnosed with breast cancer is scheduled for a partial mastectomy. The oncology nurse explained that the surgeon will want to take tissue samples to ensure the disease has not spread to adjacent axillary lymph nodes. The patient has asked if she will have her lymph nodes dissected, like her mother did several years ago. What alternative to lymph node dissection will this patient most likely undergo?

  • A. Lymphadenectomy
  • B. Needle biopsy
  • C. Open biopsy
  • D. Sentinel node biopsy
Correct Answer: D

Rationale: The correct answer is D: Sentinel node biopsy. This procedure involves identifying and removing the sentinel lymph node(s) which is the first lymph node(s) that cancer cells are likely to spread to from the primary tumor. This method helps determine if cancer has spread beyond the primary site without the need for a full axillary lymph node dissection. It is less invasive, has fewer side effects, and provides accurate staging information. Lymphadenectomy (A) refers to the removal of multiple lymph nodes, which is more extensive than necessary in this case. Needle biopsy (B) and open biopsy (C) are not specific to lymph node evaluation and do not provide accurate staging information for breast cancer.

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A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patients condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply.

  • A. Foods
  • B. Medications
  • C. Insect stings
  • D. Autoimmunity E) Environmental pollutants
Correct Answer: A

Rationale: The correct answer is A: Foods. Anaphylaxis is a severe allergic reaction that can be triggered by foods, medications, insect stings, and other allergens. In this scenario, assessing for potential food allergies is crucial as food is one of the most common triggers for anaphylaxis. Foods like nuts, shellfish, and eggs are common culprits. Medications and insect stings (choices B and C) are also important triggers to consider in the assessment. Autoimmunity (choice D) is not a direct cause of anaphylaxis, as it involves the immune system attacking the body's own tissues rather than reacting to external allergens. Environmental pollutants (choice E) may trigger respiratory symptoms but are not typically associated with anaphylaxis.

What is the priority nursing intervention for the patient who has had an incomplete abortion?

  • A. Methylergonovine (Methergine), 0.2 mg IM
  • B. Preoperative teaching for surgery
  • C. Insertion of IV line for fluid replacement
  • D. Positioning of patient in left side-lying position
Correct Answer: C

Rationale: The correct answer is C because the priority nursing intervention for a patient with incomplete abortion is to ensure adequate fluid replacement to prevent hypovolemic shock due to potential blood loss. Inserting an IV line allows for immediate administration of fluids and medications if necessary. Choice A (Methylergonovine) is used to manage postpartum hemorrhage, not incomplete abortion. Choice B (Preoperative teaching) and choice D (Positioning) are important but not the priority in this situation.

A patient has herpes simplex 2 viral infection (HSV2). The nurse recognizes that which of the following should be included in teaching the patient?

  • A. The virus causes cold sores of the lips.
  • B. The virus may be cured with antibiotics.
  • C. The virus, when active, may not be contracted during intercourse.
  • D. Treatment is aimed at relieving symptoms.
Correct Answer: D

Rationale: The correct answer is D because treatment for HSV2 focuses on relieving symptoms since the virus cannot be cured. Antiviral medications can help manage outbreaks and reduce the frequency and severity of symptoms. Option A is incorrect as HSV2 typically presents as genital herpes, not cold sores on the lips (usually caused by HSV1). Option B is incorrect since antibiotics are ineffective against viruses. Option C is incorrect as HSV2 is most contagious during active outbreaks, making it important to practice safe sex to prevent transmission.

A placenta previa when the placental edge just reaches the internal os is called

  • A. total.
  • B. partial.
  • C. low-lying.
  • D. marginal.
Correct Answer: D

Rationale: The correct answer is D, marginal. Placenta previa is classified based on the proximity of the placental edge to the internal os. In a marginal placenta previa, the placental edge just reaches the internal os. This is a crucial distinction as it poses a higher risk for bleeding during labor. Total placenta previa covers the entire internal os, partial placenta previa partially covers the internal os, and low-lying placenta is when the placenta is close to but not covering the internal os. Therefore, D is correct as it accurately describes the specific position of the placenta edge in relation to the internal os in cases of marginal placenta previa.

A patient has undergone diagnostic testing and has been diagnosed with otosclerosis? What ear structure is primarily affected by this diagnosis?

  • A. Malleus
  • B. Stapes
  • C. Incus
  • D. Tympanic membrane
Correct Answer: B

Rationale: The correct answer is B: Stapes. Otosclerosis is a condition characterized by abnormal bone growth in the middle ear, causing the stapes bone to become fixed in place. This results in hearing loss due to the inability of the stapes to transmit sound vibrations to the inner ear. The malleus (choice A), incus (choice C), and tympanic membrane (choice D) are not primarily affected by otosclerosis. The malleus and incus are located in the middle ear but are not typically affected by otosclerosis. The tympanic membrane is part of the outer ear and is not directly involved in otosclerosis.

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