foundations of nursing test bank

foundations of nursing test bank Related

Review foundations of nursing test bank related questions and content

A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patients diagnosis will be?

  • A. Ossiculitis
  • B. Mnires disease
  • C. Ototoxicity
  • D. Labyrinthitis
Correct Answer: D

Rationale: The correct answer is D: Labyrinthitis. This condition presents with sudden onset vertigo, nausea, vomiting, tinnitus, and hearing loss, which are all symptoms described by the patient. Labyrinthitis is commonly caused by a viral infection affecting the inner ear, leading to inflammation of the labyrinth. This inflammation disrupts the balance and hearing functions of the inner ear, resulting in the symptoms mentioned.

A: Ossiculitis involves inflammation of the middle ear bones, typically causing conductive hearing loss, not the sudden onset of vertigo and other symptoms described.

B: Mnire's disease is characterized by recurrent episodes of vertigo, tinnitus, and hearing loss, but it typically does not present with sudden onset incapacitating vertigo.

C: Ototoxicity is caused by exposure to certain medications or chemicals that damage the inner ear structures, leading to hearing loss. While hearing loss is a symptom, the sudden onset of vertigo is not typically associated with ototoxicity.

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A nurse has asked the nurse educator if there is any way to predict the severity of a patients anaphylactic reaction. What would be the nurses best response?

  • A. The faster the onset of symptoms, the more severe the reaction.
  • B. The reaction will be about one-third more severe than the patients last reaction to the same antigen.
  • C. There is no way to gauge the severity of a patients anaphylaxis, even if it has occurred repeatedly in the past.
  • D. The reaction will generally be slightly less severe than the last reaction to the same antigen.
Correct Answer: C

Rationale: The correct answer is C because the severity of an anaphylactic reaction can vary greatly from one episode to another in the same patient. Anaphylactic reactions are unpredictable and can be influenced by various factors such as the amount of allergen exposure, individual immune response, underlying health conditions, and concurrent medications. Therefore, it is not possible to reliably gauge the severity of a patient's anaphylactic reaction even if it has occurred repeatedly in the past.

Choice A is incorrect because the onset of symptoms alone is not a reliable predictor of the severity of the reaction. Choice B is incorrect as well because there is no set formula to predict that the reaction will be one-third more severe than the patient's last reaction. Choice D is incorrect because stating that the reaction will generally be slightly less severe than the last reaction is also not accurate or supported by evidence.

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.

Nursing intervention for pregnant patients with diabetes is based on the knowledge that the need for insulin is

  • A. varied depending on the stage of gestation.
  • B. increased throughout pregnancy and the postpartum period.
  • C. decreased throughout pregnancy and the postpartum period.
  • D. should not change because the fetus produces its own insulin.
Correct Answer: A

Rationale: Rationale:
1. Insulin needs change during pregnancy due to hormonal changes.
2. During the first trimester, insulin needs may decrease.
3. During the second and third trimesters, insulin needs increase.
4. Postpartum, insulin needs return to pre-pregnancy levels.
Therefore, choice A is correct as insulin needs vary based on gestational stage. Choices B, C, and D are incorrect because insulin needs do not uniformly increase or decrease throughout pregnancy or due to fetal insulin production.

The nurse is teaching a health class about theChooseMyPlateprogram. Which guidelines will thenurse include in the teaching session?

  • A. Balancing sodium and potassium
  • B. Decreasing water consumption
  • C. Increasing portion size
  • D. Balancing calories
Correct Answer: D

Rationale: The correct answer is D, balancing calories. This is because the ChooseMyPlate program emphasizes the importance of maintaining a balance between the calories consumed and calories expended for overall health and weight management. By balancing calories, individuals can ensure they are meeting their nutritional needs without overeating or consuming excess calories.

A: Balancing sodium and potassium is important for managing blood pressure, but this is not a specific guideline of the ChooseMyPlate program.
B: Decreasing water consumption is not a guideline of the ChooseMyPlate program. Adequate hydration is essential for overall health.
C: Increasing portion size is not recommended in the ChooseMyPlate program. It emphasizes portion control and eating appropriate serving sizes of different food groups.

The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do?

  • A. Increase the rate to get the volume caught up before discontinuing.
  • B. Stop the infusion as ordered.
  • C. Taper infusion gradually.
  • D. Hang 5% dextrose.
Correct Answer: C

Rationale: Rationale for Correct Answer (C - Taper infusion gradually):
1. Tapering the infusion gradually allows for a smooth transition off PN without causing metabolic disturbances.
2. Abruptly stopping PN can lead to hypoglycemia and electrolyte imbalances.
3. Increasing the rate may cause fluid overload or hyperglycemia.
4. Hanging 5% dextrose alone does not provide adequate nutrition and may not meet the patient's needs.

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