foundations of nursing test bank

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Review foundations of nursing test bank related questions and content

A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style. A home health nurse is preparing for an initialhome visit. Which information should be included in the patient’s home care medical record?

  • A. Nursing process form
  • B. Step-by-step skills manual
  • C. A list of possible procedures
  • D. Reports to third-party payers
Correct Answer: D

Rationale: The correct answer is D: Reports to third-party payers. In home health care, it is essential to document and report patient care to third-party payers for reimbursement purposes. This includes detailed reports on the services provided, patient progress, and any changes in the care plan. This information is crucial for ensuring that the patient receives appropriate reimbursement for the care received.

Incorrect choices:
A: Nursing process form - While a nursing process form is important for documenting patient care, it is not specifically related to reporting to third-party payers.
B: Step-by-step skills manual - While a skills manual may be helpful for guiding care provision, it is not typically included in the patient's medical record.
C: A list of possible procedures - While a list of procedures may be useful for reference, it is not a formal part of the patient's medical record for home care documentation.

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In determining malnourishment in a patient, which assessment finding is consistent with this disorder?

  • A. Moist lips
  • B. Pink conjunctivae
  • C. Spoon-shaped nails
  • D. Not easily plucked hair
Correct Answer: C

Rationale: Step 1: Malnourishment often leads to iron deficiency anemia, causing spoon-shaped nails (koilonychia).
Step 2: Koilonychia is a classic sign of chronic malnutrition and iron deficiency.
Step 3: Moist lips (A) and pink conjunctivae (B) are not specific to malnourishment.
Step 4: Not easily plucked hair (D) is more related to hair health rather than malnutrition.

A high-risk labor patient progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean birth. Which finding in the immediate postoperative period indicates that the patient is at risk of developing HELLP syndrome?

  • A. Platelet count of 50,000/mcL
  • B. Liver enzyme levels within normal range
  • C. Negative for edema
  • D. No evidence of nausea or vomiting
Correct Answer: A

Rationale: The correct answer is A: Platelet count of 50,000/mcL. HELLP syndrome is a severe form of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. In this scenario, a platelet count of 50,000/mcL indicates thrombocytopenia, which is a key component of HELLP syndrome. Low platelet count can lead to bleeding complications and is a critical indicator of the syndrome.

Choices B, C, and D are incorrect.
B: Liver enzyme levels within normal range do not necessarily indicate the presence of HELLP syndrome, as elevated liver enzymes are a hallmark feature of the syndrome.
C: Being negative for edema is not a reliable indicator of HELLP syndrome, as edema is a common finding in preeclampsia but not specific to HELLP syndrome.
D: No evidence of nausea or vomiting is not a specific sign of HELLP syndrome, as these

A patient has just been told that her illness is terminal. The patient tearfully states, I cant believe I am going to die. Why me? What is your best response?

  • A. I know how you are feeling.
  • B. You have lived a long life.
  • C. This must be very difficult for you.
  • D. Life can be so unfair.
Correct Answer: C

Rationale: The correct answer is C: "This must be very difficult for you." This response acknowledges the patient's emotional state and shows empathy without making assumptions or dismissing their feelings. It validates the patient's emotions and opens up the opportunity for further discussion or support.

Rationale:
1. A: "I know how you are feeling" assumes the tutor knows the exact emotions of the patient, which can come off as insincere or dismissive.
2. B: "You have lived a long life" does not address the patient's emotional distress or provide comfort in the face of a terminal illness.
3. D: "Life can be so unfair" does not directly address the patient's feelings and may come off as generic or cliché.

The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What is a priority nursing diagnosis for this patient?

  • A. Fatigue related to altered metabolic processes
  • B. Altered nutrition: less than body requirements related to anorexia
  • C. Risk for infection related to altered immunologic response
  • D. Body image disturbance related to weight loss and anorexia
Correct Answer: C

Rationale: The correct answer is C: Risk for infection related to altered immunologic response. This is the priority nursing diagnosis for a patient preparing for hematopoietic stem cell transplant (HSCT) because the patient's immune system will be severely compromised post-transplant, leading to a high risk of infections. It is crucial to prioritize infection prevention to ensure the patient's safety and well-being.

Choice A is incorrect because while fatigue is common in cancer patients, it is not the priority in this case where infection risk is higher. Choice B is incorrect as altered nutrition can be addressed after managing the risk for infection. Choice D is incorrect as body image disturbance is important but not as critical as preventing infections in this highly vulnerable patient population.

A nurse is sitting at the patient’s bedside takinga nursing history. Which zone of personal space is the nurse using?

  • A. Socio-consultative
  • B. Personal
  • C. Intimate
  • D. Public
Correct Answer: B

Rationale: The nurse sitting at the patient's bedside is using the personal zone of personal space, which ranges from 18 inches to 4 feet. This distance allows for a close interaction suitable for taking a nursing history while maintaining a professional yet personal connection. The socio-consultative zone (A) is 4-12 feet, more appropriate for professional interactions. The intimate zone (C) is 0-18 inches, too close for an initial nursing history. The public zone (D) is 12 feet or more, too distant for a personal conversation.

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