foundations of nursing test bank

foundations of nursing test bank Related

Review foundations of nursing test bank related questions and content

A patient has just returned to the postsurgical unit from post-anesthetic recovery after breast surgery for removal of a malignancy. What is the most likely major nursing diagnosis to include in this patients immediate plan of care?

  • A. Acute pain related to tissue manipulation and incision
  • B. Ineffective coping related to surgery
  • C. Risk for trauma related to post-surgical injury
  • D. Chronic sorrow related to change in body image
Correct Answer: A

Rationale: The correct answer is A: Acute pain related to tissue manipulation and incision. This is the most likely major nursing diagnosis because post-surgical pain is a common and expected occurrence after breast surgery. The patient is likely to experience pain due to tissue manipulation and incision during the surgery. Addressing acute pain is crucial for the patient's comfort, well-being, and overall recovery.

Choice B (Ineffective coping related to surgery) may be a secondary nursing diagnosis, but acute pain takes priority as it directly impacts the patient's immediate comfort and recovery. Choice C (Risk for trauma related to post-surgical injury) is not the most appropriate nursing diagnosis since the patient has already undergone surgery and is not at risk for further injury at this point. Choice D (Chronic sorrow related to change in body image) is not the most immediate concern post-surgery; addressing acute pain is more critical.

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An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?

  • A. Apply an ice pack or heating pad PRN to relieve pain and pruritis
  • B. Avoid skin contact with water whenever possible
  • C. Apply phototherapy PRN
  • D. Avoid rubbing or scratching the affected area
Correct Answer: D

Rationale: Correct Answer: D - Avoid rubbing or scratching the affected area

Rationale:
1. Rubbing or scratching can further damage the already compromised skin integrity.
2. By avoiding rubbing or scratching, the patient reduces the risk of infection and delayed healing.
3. This intervention promotes skin healing and prevents worsening of the condition.

Summary:
A: Applying ice pack or heating pad may provide temporary relief but does not address the root cause of impaired skin integrity.
B: Avoiding skin contact with water is not necessary and may not directly improve skin integrity.
C: Phototherapy is not indicated for erythematous reactions to radiation therapy and may not address the issue.

A patients primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the patients immune response. This physiologic state is known as which of the following?

  • A. Static stage
  • B. Latent stage
  • C. Viral set point
  • D. Window period
Correct Answer: C

Rationale: The correct answer is C: Viral set point. The viral set point refers to the stable level of HIV in the body after the initial infection. This state indicates a balance between viral replication and the immune response. The other choices are incorrect because: A) Static stage implies no change, which is not the case with HIV levels fluctuating; B) Latent stage refers to a period of inactivity, not the stable state described; D) Window period is the time between infection and detectable antibodies, not the equilibrium state described.

A patient with severe environmental allergies is scheduled for an immunotherapy injection. What should be included in teaching the patient about this treatment?

  • A. The patient will be given a low dose of epinephrine before the treatment.
  • B. The patient will remain in the clinic to be monitored for 30 minutes following the injection.
  • C. Therapeutic failure occurs if the symptoms to the allergen do not decrease after 3 months.
  • D. The allergen will be administered by the peripheral intravenous route. .
Correct Answer: B

Rationale: Step 1: Immunotherapy injections can cause allergic reactions.
Step 2: Monitoring post-injection is crucial to detect and manage any potential adverse reactions promptly.
Step 3: Staying in the clinic for 30 minutes allows for immediate intervention if needed.
Step 4: This ensures patient safety and reduces the risk of severe reactions.
Summary:
A: Epinephrine is not typically given before immunotherapy injections.
C: Therapeutic response may take longer than 3 months to show.
D: Immunotherapy is usually given via subcutaneous route, not intravenous.

A nurse practitioner is assessing a 55-year-old male patient who is complaining of perineal discomfort, burning, urgency, and frequency with urination. The patient states that he has pain with ejaculation. The nurse knows that the patient is exhibiting symptoms of what?

  • A. Varicocele
  • B. Epididymitis
  • C. Prostatitis
  • D. Hydrocele
Correct Answer: C

Rationale: The correct answer is C: Prostatitis. The patient's symptoms of perineal discomfort, burning, urgency, frequency with urination, and pain with ejaculation are indicative of prostatitis. Prostatitis is inflammation of the prostate gland, leading to these symptoms. Varicocele (A) is an enlargement of the veins within the scrotum, usually painless. Epididymitis (B) is inflammation of the epididymis, causing scrotal pain and swelling. Hydrocele (D) is a fluid-filled sac around the testicle, typically painless. The patient's symptoms align most closely with prostatitis due to the involvement of the prostate gland and the specific urinary and ejaculatory symptoms experienced.

A 55-year-old man presents at the clinic complaining of erectile dysfunction. The patient has a history of diabetes. The physician orders tadalafil (Cialis) to be taken 1 hour before sexual intercourse. The nurse reviews the patients history prior to instructing the patient on the use of this medication. What disorder will contraindicate the use of tadalafil (Cialis)?

  • A. Cataracts
  • B. Retinopathy
  • C. Hypotension
  • D. Diabetic nephropathy
Correct Answer: B

Rationale: The correct answer is B: Retinopathy. Tadalafil (Cialis) is contraindicated in patients with retinopathy due to the potential risk of worsening vision problems. Retinopathy is a serious eye condition commonly associated with diabetes, and using tadalafil can lead to further complications in the eyes. It is crucial for patients with retinopathy to avoid medications that can exacerbate their eye condition.

Incorrect choices:
A: Cataracts - Cataracts do not contraindicate the use of tadalafil. Tadalafil does not have a direct negative impact on cataracts.
C: Hypotension - Hypotension is not a contraindication for tadalafil use. In fact, tadalafil can cause a drop in blood pressure, so it should be used with caution in patients with hypotension.
D: Diabetic nephropathy - Diabetic nephropathy is not a direct contraindication for tadalafil use. Tadalafil is generally

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