foundation of nursing questions

foundation of nursing questions Related

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A 67-year-old woman experienced the death of her husband from a sudden myocardial infarction 5 weeks ago. The nurse recognizes that the woman will be going through the process of mourning for an extended period of time. What processes of mourning will allow the woman to accommodate the loss in a healthy way? Select all that apply.

  • A. Reiterating her anger at her husbands care team
  • B. Reinvesting in new relationships at the appropriate time
  • C. Reminiscing about the relationship she had with her husband
  • D. Relinquishing old attachments to her husband at the appropriate time E) Renewing her lifelong commitment to her husband
Correct Answer: B

Rationale: The correct answer is B: Reinvesting in new relationships at the appropriate time. This process of mourning involves the woman gradually shifting her focus from the past relationship with her husband to forming new relationships or reinvesting in existing ones. This is crucial for her to adapt to life without her husband and move forward in a healthy manner.

A: Reiterating her anger at her husband's care team is not a healthy process as it can lead to prolonged resentment and hinder the mourning process.

C: Reminiscing about the relationship she had with her husband is a natural part of mourning but solely focusing on reminiscing may not allow her to fully adapt to life without her husband.

D: Relinquishing old attachments to her husband at the appropriate time is important, but it is only one aspect of the mourning process. It is not the sole process necessary for healthy mourning.

E: Renewing her lifelong commitment to her husband is not a healthy process as it prevents her from accepting the loss and

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After providing care, a nurse charts in the patient’srecord. Which entry will the nurse document?

  • A. Appears restless when sitting in the chair
  • B. Drank adequate amounts of water
  • C. Apparently is asleep with eyes closed
  • D. Skin pale and cool
Correct Answer: D

Rationale: The correct answer is D because documenting the skin condition is an objective assessment that provides vital information about the patient's health status. Pale and cool skin may indicate poor perfusion or circulation issues. This observation is crucial for monitoring the patient's condition and identifying any potential concerns. Choices A, B, and C are subjective and do not provide specific or relevant information related to the patient's overall health status or response to care. Without objective data like skin appearance, it would be challenging to assess the patient's condition accurately.

A patient, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease?

  • A. Metastasis
  • B. Risk for stroke
  • C. Emotional and personality changes
  • D. Pathologic bone fractures
Correct Answer: C

Rationale: The correct answer is C: Emotional and personality changes. In Huntington disease, neurodegeneration affects the brain, leading to changes in behavior, emotions, and personality. These changes are characteristic of the disease progression. Metastasis (A) refers to the spread of cancer, which is not associated with Huntington disease. Risk for stroke (B) is not a typical manifestation of Huntington disease. Pathologic bone fractures (D) are not directly related to the primary symptoms of Huntington disease. Thus, addressing emotional and personality changes is crucial in providing anticipatory guidance for individuals with Huntington disease.

When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?

  • A. Loss of muscle tone in the vaginal wall
  • B. Excessive synthesis and release of unopposed estrogen
  • C. Invasion of the uterine wall by endometrial tissue
  • D. Proliferation of tumors in the uterine wall
Correct Answer: C

Rationale: The correct answer is C: Invasion of the uterine wall by endometrial tissue. Adenomyosis is a condition where endometrial tissue grows into the muscular wall of the uterus, causing symptoms like heavy menstrual bleeding and severe cramping. This process results in inflammation, thickening of the uterine wall, and can lead to enlargement of the uterus.

Choice A: Loss of muscle tone in the vaginal wall is incorrect because adenomyosis does not involve the vaginal wall.

Choice B: Excessive synthesis and release of unopposed estrogen is incorrect because although estrogen can contribute to the growth of endometrial tissue, it is not the primary pathophysiologic process in adenomyosis.

Choice D: Proliferation of tumors in the uterine wall is incorrect because adenomyosis does not involve the growth of tumors, but rather the infiltration of endometrial tissue into the uterine muscle.

The nurse is caring for a patient with a diagnosis of vulvar cancer who has returned from the PACU after undergoing a wide excision of the vulva. How should this patients analgesic regimen be best managed?

  • A. Analgesia should be withheld unless the patients pain becomes unbearable.
  • B. Scheduled analgesia should be administered around-the-clock to prevent pain.
  • C. All analgesics should be given on a PRN, rather than scheduled, basis.
  • D. Opioid analgesics should be avoided and NSAIDs exclusively provided.
Correct Answer: B

Rationale: The correct answer is B: Scheduled analgesia should be administered around-the-clock to prevent pain. After undergoing a wide excision of the vulva, the patient is likely to experience significant pain. Scheduled analgesia ensures that the patient receives pain relief consistently, preventing pain from becoming severe. This approach helps to maintain a therapeutic level of pain control and improves patient comfort and satisfaction.

Choice A is incorrect because withholding analgesia until the pain becomes unbearable can lead to unnecessary suffering and poor pain management. Choice C is incorrect as PRN dosing may result in inadequate pain relief and fluctuations in pain control. Choice D is incorrect as opioids are often necessary for postoperative pain management, and NSAIDs alone may not provide sufficient relief for the level of pain associated with a wide excision surgery.

A nurse is caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?

  • A. Forearm
  • B. Thigh
  • C. Deltoid muscle
  • D. Abdomen
Correct Answer: B

Rationale: The correct answer is B: Thigh. When administering epinephrine during an anaphylactic reaction, the thigh is the recommended site due to its large muscle mass and quick absorption rate. Steps: 1. Remove safety cap. 2. Firmly push the auto-injector against the thigh until it clicks. 3. Hold in place for a few seconds. 4. Seek medical help immediately. Rationale for incorrect choices: A: Forearm - Not recommended due to smaller muscle mass and slower absorption. C: Deltoid muscle - Not preferred as it may not provide as rapid absorption as the thigh. D: Abdomen - Not ideal due to potential fat layers that could affect absorption speed.

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