Foundation Of Nursing Test IV - Set A

The correct answer is the best response because it shows empathy and understanding towards Mrs. Lim's emotions. It acknowledges the difficulty she is experiencing and offers reassurance that her hair will grow back after completing chemotherapy. This response shows support and compassion, providing Mrs. Lim with the emotional comfort she needs in that moment.

Alzheimer's disease is the most common cause of dementia among elderly persons. It is a progressive brain disorder that affects memory, thinking, and behavior. It is characterized by the buildup of amyloid plaques and tau tangles in the brain, leading to the death of brain cells and a decline in cognitive function. Symptoms of Alzheimer's disease include memory loss, confusion, difficulty with language and problem-solving, and changes in mood and behavior. While Parkinson's disease, multiple sclerosis, and amyotrophic lateral sclerosis can also cause cognitive impairment, they are not as commonly associated with dementia as Alzheimer's disease.

The statement "The patient should always feed himself" is incorrect. Patients with dysphagia may have difficulty swallowing and may require assistance with feeding. The nurse should assess the patient's ability to swallow safely and provide the necessary support and assistance during meal times to prevent choking or aspiration.

The 88-year old incontinent patient with gastric cancer who is confined to his bed at home is at the greatest risk for developing pressure ulcers. This patient is at risk due to multiple factors: being elderly, having a medical condition (gastric cancer), being incontinent, and being confined to bed. Immobility, incontinence, and poor nutritional status are all risk factors for the development of pressure ulcers. Additionally, the patient's age and underlying medical condition may further compromise their skin integrity and ability to heal, increasing their risk for pressure ulcers.

All of the above nursing interventions promote patient safety. Assessing the patient's ability to ambulate and transfer from a bed to a chair ensures that the patient can move safely without the risk of falls or injuries. Demonstrating the signal system to the patient allows them to call for help in case of emergencies or when they need assistance. Checking that the patient is wearing their identification band helps to ensure that they receive the correct treatments and medications, minimizing the risk of errors.

As people age, their bones become more fragile and prone to fractures. The hip is one of the most commonly affected areas in elderly individuals. Hip fractures can occur due to a fall or even a minor injury, and they can have serious consequences, leading to decreased mobility, increased dependence, and a higher risk of complications such as pneumonia or blood clots. Therefore, hip fractures are the most common injury among elderly persons.

Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is the heartbeat that is felt at the apex of the heart, which is located in the fifth intercostal space at the midclavicular line. By palpating this area, healthcare professionals can accurately assess the rate, rhythm, and strength of the heartbeat. This technique allows for a more accurate assessment of the heart's function and can help identify any abnormalities or irregularities in the pulse.

The patient's symptoms of shortness of breath, orthopnea, and thick, tenacious secretions indicate that their airway is not effectively clearing mucus. This is likely due to the thick secretions obstructing the airway, leading to difficulty in breathing. Therefore, the appropriate nursing diagnosis would be "Ineffective airway clearance related to thick, tenacious secretions." This diagnosis addresses the specific issue of the patient's airway being obstructed by the thick secretions and identifies it as the cause of their symptoms.

As a person ages, several changes occur in the vascular system. One of these changes is an increase in peripheral resistance of the blood vessels, which means that the blood vessels become narrower and it becomes more difficult for the blood to flow through them. Additionally, there is a decrease in blood flow, which further contributes to the reduced efficiency of the circulatory system. Lastly, the increased workload of the left ventricle is another consequence of aging, as it has to pump harder to compensate for the changes in the blood vessels. Therefore, all of the given options are correct and represent vascular system changes that result from aging.

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Parasympathetic nervous system stimulation is not a cause of tachycardia. Tachycardia refers to an abnormally fast heart rate, typically above 100 beats per minute. Fever, exercise, and sympathetic nervous system stimulation can all lead to an increase in heart rate. However, parasympathetic nervous system stimulation, which is responsible for slowing down the heart rate, would not cause tachycardia.

Caffeine-containing drinks, such as coffee and cola, increase the amount of urine produced. Caffeine is a diuretic, which means it promotes urine production by increasing the blood flow to the kidneys and inhibiting the reabsorption of water. This results in more urine being produced and expelled from the body.

Thiamine deficiency is the most common deficiency seen in alcoholics. Alcohol interferes with the absorption, storage, and utilization of thiamine in the body. Thiamine is an essential B vitamin that plays a crucial role in energy metabolism and the functioning of the nervous system. Chronic alcohol consumption can lead to a decrease in thiamine levels, which can result in a condition called Wernicke-Korsakoff syndrome, characterized by neurological symptoms such as confusion, memory loss, and coordination problems. Therefore, alcoholics are at a higher risk of thiamine deficiency compared to other vitamin deficiencies.

The absence of the pedal pulse may not be a significant finding when a patient is admitted to the hospital because the pedal pulse refers to the pulse in the foot. In certain situations, such as when a patient has peripheral artery disease or is wearing compression stockings, the pedal pulse may not be easily palpable or may be weak. Therefore, its absence alone may not be a cause for concern, as there are other pulses that can be assessed to evaluate the patient's circulatory status.

The patient had surgery for head and neck cancer, which can have significant effects on balance and vision. Even though the nurse notes that the patient is steady on his feet and his vision is unaffected, it is still important to accompany the patient for his walk. This is a precautionary measure to ensure the patient's safety and provide support if any issues arise during ambulation. Consulting a physical therapist may also be beneficial, but the immediate action would be to accompany the patient for his walk.

After a patient's death in a hospital, the nurse's most important legal responsibility is to label the corpse appropriately. This is crucial for maintaining accurate records and ensuring proper identification of the deceased individual. Proper labeling helps in preventing any confusion or mix-up during the subsequent processes such as transportation, autopsy, or funeral arrangements. It also aids in maintaining the chain of custody and complying with legal and regulatory requirements related to handling and disposition of deceased individuals.

In the terminal stages of lung cancer, when a patient starts to lose consciousness, protecting the patient from injury becomes a major nursing priority. This is because loss of consciousness can lead to a loss of control over body movements, making the patient more prone to accidents or falls. By ensuring a safe environment and taking measures to prevent injuries, nurses can help maintain the patient's overall well-being and minimize any potential harm.

The statement "The patient should always feed himself" is incorrect because a patient with dysphagia may require assistance with feeding. Dysphagia can make swallowing difficult and increase the risk of choking or aspiration. Therefore, it is important for the nurse or caregiver to assist the patient with feeding, ensuring that the food is prepared appropriately and that the patient is in a safe position during the process.

Depression is the most common psychogenic disorder among elderly individuals. It is characterized by symptoms such as sleep disturbances, inability to concentrate, and decreased appetite. Depression can have a significant impact on the overall well-being and quality of life of elderly individuals. It is important to recognize and address depression in this population as it can often be overlooked or mistaken for normal aging. Treatment options, including therapy and medication, can help alleviate symptoms and improve the mental health of elderly individuals affected by depression.

Increasing the patient's fluid intake can help to thin and loosen the secretions, making it easier for the patient to cough them up and improve gas exchange. This intervention can help to prevent further complications and promote better respiratory function.

A patient who cannot care for himself at home may not necessarily have impaired awareness. Impaired awareness refers to a lack of understanding or recognition of one's own condition or situation. While a patient who cannot care for himself at home may have physical limitations or disabilities, it does not necessarily mean that they have impaired awareness.

The correct answer is "Inhibition of the respiratory hypoxic stimulus". In patients with COPD, their respiratory drive is primarily stimulated by low oxygen levels in the blood. Therefore, if the patient receives too much supplemental oxygen, it can inhibit this hypoxic drive and lead to respiratory depression or hypoventilation. This is why it is important to carefully titrate the amount of oxygen given to COPD patients to avoid this potential complication.

During young adulthood, the body is typically in its prime and able to meet its nutritional needs through a balanced diet. Infancy, childhood, and pregnancy, on the other hand, are periods of rapid growth and development where additional vitamin C is crucial. Vitamin C is essential for healthy immune function, collagen synthesis, and iron absorption, making it particularly important during these stages. Therefore, young adulthood does not require additional vitamin C supplementation compared to the other mentioned periods.

The correct answer is "Side rails are a reminder to a patient not to get out of bed." This conclusion is based on the fact that despite the use of side rails, 40% of patients still fall out of bed. This suggests that side rails alone are not enough to prevent falls, but they serve as a visual reminder to patients to stay in bed and not attempt to get out.

Placing one pillow under the body's head and shoulders is the correct answer because it helps to maintain proper body alignment and prevent pooling of blood in the head and neck area. This position also allows for a more natural and comfortable appearance of the deceased. Providing a complete bath and dressing change, removing the body's clothing and wrapping the body in a shroud, or allowing the body to relax normally are not tasks that are typically performed before rigor mortis occurs.