foundation of nursing questions

foundation of nursing questions Related

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The nurse in a pediatric ICU is caring for a child who is dying of sickle cell anemia. The childs mother has been unable to eat or sleep and can talk only about her impending loss and the guilt she feels about the childs pain and suffering. What intervention has the highest priority?

  • A. Allowing the patient to express her feelings without judging her
  • B. Helping the patient to understand the phases of the grieving process
  • C. Reassuring the patient that the childs death is not her fault
  • D. Arranging for genetic counseling to inform the patient of her chances of having another child with the disease
Correct Answer: A

Rationale: The correct answer is A: Allowing the patient to express her feelings without judging her. This intervention has the highest priority as it focuses on providing emotional support and creating a safe space for the mother to express her emotions without feeling judged. In this situation, the mother is experiencing intense guilt and grief, and allowing her to talk about her feelings can help her process her emotions and cope with the impending loss. By listening actively and without judgment, the nurse can demonstrate empathy and compassion, which are crucial in supporting the mother through this difficult time.

Summary:
B: Helping the patient to understand the phases of the grieving process may be helpful, but it is not the highest priority at this moment.
C: Reassuring the patient that the child's death is not her fault is important, but the priority is to address the mother's emotional needs first.
D: Arranging for genetic counseling is not the highest priority at this time as the immediate focus should be on providing emotional support to the mother

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A woman calls the clinic and tells the nurse she has had bloody drainage from her right nipple. The nurse makes an appointment for this patient, expecting the physician or practitioner to order what diagnostic test on this patient?

  • A. Breast ultrasound
  • B. Radiography
  • C. Positron emission testing (PET)
  • D. Galactography Chapter 59: Male Reproductive: Terminologies PLISSIT Model, Prostate Cancer, Testicular cancer, BPH & Erectile dysfunction (ED)
Correct Answer: A

Rationale: The correct answer is A: Breast ultrasound. Bloody drainage from the nipple can be indicative of various conditions such as breast cancer. A breast ultrasound is a non-invasive imaging test that can help visualize any abnormalities in the breast tissue, including masses or tumors. It is commonly used to evaluate breast symptoms like nipple discharge. Radiography (B) is not typically used for evaluating breast conditions. Positron emission testing (PET) (C) is more commonly used in cancer staging and may not be the first-line test for this symptom. Galactography (D) is a specific imaging test used to evaluate the ducts of the breast and may not be the initial test for bloody nipple discharge.

A nurse is completing an OASIS data set on apatient. The nurse works in which area?

  • A. Home health
  • B. Intensive care unit
  • C. Skilled nursing facility
  • D. Long-term care facility
Correct Answer: A

Rationale: The correct answer is A: Home health. The Outcome and Assessment Information Set (OASIS) data set is specifically used in the home health care setting to assess the patient's condition and needs. This includes collecting data on the patient's health, functional status, and living environment to determine the appropriate care plan. In contrast, choices B, C, and D are incorrect because OASIS is not utilized in the intensive care unit, skilled nursing facility, or long-term care facility settings. These settings have their own assessment tools and documentation requirements that are different from OASIS used in home health care.

A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The patient has just exhibited seizure activity for the first time. What is the nurses priority response to this event?

  • A. Identify the triggers that precipitated the seizure.
  • B. Implement precautions to ensure the patients safety.
  • C. Teach the patients family about the relationship between brain tumors and seizure activity.
  • D. Ensure that the patient is housed in a private room.
Correct Answer: B

Rationale: The correct answer is B: Implement precautions to ensure the patient's safety. When a patient exhibits seizure activity for the first time, the immediate priority is to ensure the patient's safety by implementing precautions such as protecting the patient from injury during the seizure, ensuring a patent airway, and monitoring vital signs. Identifying triggers (Choice A) can be important for long-term management but is not the priority during an acute seizure. Teaching the family about the relationship between brain tumors and seizures (Choice C) can be done later but is not the immediate priority. Ensuring a private room (Choice D) is not the priority when the patient's safety during a seizure is the main concern.

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 nurse who provides care on an acute medical unit has observed that physicians are frequently reluctant to refer patients to hospice care. What are contributing factors that are known to underlie this tendency? Select all that apply.

  • A. Financial pressures on health care providers
  • B. Patient reluctance to accept this type of care
  • C. Strong association of hospice care with prolonging death
  • D. Advances in curative treatment in late-stage illness E) Ease of making a terminal diagnosis
Correct Answer: A

Rationale: The correct answer is A: Financial pressures on health care providers. Physicians may be reluctant to refer patients to hospice care due to financial pressures. This could be because hospice care may be seen as less profitable compared to other treatments or services. Other choices are incorrect because: B: Patient reluctance is not a contributing factor from the physician's perspective. C: Hospice care is actually focused on comfort and quality of life, not prolonging death. D: Advances in curative treatment may not be directly related to physician reluctance to refer to hospice. E: Ease of making a terminal diagnosis is not a significant factor influencing physician reluctance.

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