Foundations of Nursing (PNR 106)

The correct answer is B: Rituals

Explanation:

Rituals refer to specific practices, often prescribed by religious or spiritual beliefs, that guide behaviors related to health, illness, birth, and death. These are structured and often repeated actions or ceremonies that hold significance within the context of a religion or spirituality.

Why the Other Options Are Incorrect:

A. Culture:

Culture is a broader term that encompasses the entire way of life of a group, including language, traditions, food, and more, and is not solely related to religious or spiritual practices.

C. Religion:

While religion does involve practices and beliefs related to health, illness, and death, it is a broader concept that includes the entire system of faith and worship, not just the specific practices or actions (rituals).

D. Muslim Beliefs About Death:

This is a specific example of religious beliefs, not the overarching term for health-related practices in a religion.

Summary:

Rituals are the specific actions or ceremonies related to health, illness, birth, and death, often prescribed by religious or spiritual traditions.

The correct answer is B: Respiratory alkalosis

Explanation:

Hyperventilation causes the patient to exhale excess carbon dioxide (CO2) rapidly. This loss of CO2 results in a decrease in the concentration of carbonic acid in the blood, leading to an increase in the blood's pH (alkalosis). This condition is known as respiratory alkalosis, where the pH of the blood rises above 7.45, and the Paco2 (partial pressure of carbon dioxide) falls below 35 mmHg.

Why the Other Options Are Incorrect

A. Respiratory acidosis:

This occurs when there is an accumulation of CO2 in the blood, typically caused by hypoventilation or impaired lung function, not hyperventilation.

C. Metabolic acidosis:

This condition is usually due to an accumulation of acids (other than CO2) or a loss of bicarbonate, not typically caused by hyperventilation.

D. Metabolic alkalosis:

This occurs when there is an excess of bicarbonate or loss of acid from the body, which is not typically a result of hyperventilation.

Summary:

The most likely acid-base imbalance caused by hyperventilation is respiratory alkalosis due to the excessive loss of CO2, leading to an elevated blood pH. Monitoring the patient for signs such as lightheadedness, confusion, and tingling can help manage this condition.

The correct answer is A: The urine concentration is within the normal range

Explanation:

Urine specific gravity measures the concentration of solutes in the urine and reflects the kidney's ability to concentrate or dilute urine. The normal range for urine specific gravity is 1.010 to 1.030. A value of 1.025 falls within this range, meaning the urine concentration is normal.

Why the Other Options Are Incorrect:

B. The patient is likely overhydrated:

Overhydration typically results in a low urine specific gravity, closer to 1.010 or lower. When there is excessive fluid intake, the kidneys dilute the urine, leading to a lower concentration of solutes. Since 1.025 is within the normal range, this does not indicate overhydration.

C. The patient is experiencing severe dehydration:

Severe dehydration leads to very concentrated urine with a specific gravity above 1.030. A higher value suggests the kidneys are conserving water by producing more concentrated urine. Since 1.025 is within the normal range, it does not indicate severe dehydration.

D. The urine is excessively diluted and may indicate kidney failure:

In conditions like chronic kidney disease or diabetes insipidus, the kidneys may lose their ability to concentrate urine, resulting in a very low specific gravity (below 1.005). Since 1.025 is within the normal range, it does not suggest kidney failure or excessive dilution.

Summary:

The normal urine specific gravity range is 1.010 to 1.030. A value of 1.025 is within normal limits, indicating appropriate kidney function and hydration status. Low values (<1.010) suggest overhydration or kidney issues, while high values (>1.030) indicate dehydration. Proper interpretation of specific gravity helps assess fluid balance and renal function in patients.

The correct answer is D: Spirituality

Explanation:

Spirituality refers to an individual's subjective experience and sense of connection to something greater than oneself. It encompasses beliefs, practices, and experiences that focus on the meaning of life, one's relationship to the physical and non-physical world, and often the quest for understanding the nature of existence. The term "breath of life" often symbolizes the connection between the body and spirit, representing the essence of life and one's deeper connection to the universe and the divine.

Why the Other Options Are Incorrect:

A. Cultural relativism:

Cultural relativism is the belief that all cultural practices and beliefs should be understood within their own context, and not judged by the standards of another culture. While it may relate to cultural beliefs about life, it does not address the subjective experience of life's meaning or the connection to the physical and non-physical world.

B. Eastern Orthodox beliefs about birth:

Eastern Orthodox beliefs about birth focus on religious rites such as baptism, but they do not encompass the broader concept of spirituality as it relates to a person's subjective experience of the meaning of life.

C. Vegan:

Veganism refers to a lifestyle and dietary choice that excludes animal products. While it can be influenced by spiritual beliefs, it is not inherently related to the broader concept of spirituality or the "breath of life."

Summary:

The description of "breath of life" as a subjective experience explaining one's relationship to the physical and non-physical world aligns best with spirituality. Spirituality encompasses the search for meaning, the connection to existence, and one's relationship to the universe.

The correct answer isA):  Fibrin clots are formed

Explanation:

After an injury to the skin, especially with a partial thickness wound, the first step in the body's natural healing process is the formation of a fibrin clot. This clot helps to stop bleeding and provides a scaffold for the subsequent healing stages, such as inflammation and tissue regeneration. It plays a crucial role in wound closure and protecting the wound from infection.

Why the Other Options Are Incorrect:

B) Collagen is deposited: While collagen is essential for wound healing, it is typically deposited in the later stages of the healing process after the initial clot formation and inflammation.

C) Granulation tissue is formed: Granulation tissue forms in the proliferative phase, following clot formation and the inflammatory stage. It consists of new blood vessels and connective tissue that help repair the wound.

D) Scar tissue is formed: Scar tissue is the final result of wound healing and is formed after the tissue has regenerated. It typically forms after collagen deposition and granulation tissue formation.

Summary:

In a partial thickness wound, the first step is the formation of fibrin clots, which help stop the bleeding and set the stage for the subsequent phases of healing. This is the initial step before collagen deposition, granulation tissue formation, and eventual scarring

The correct answer is:A) The nurse states, I’m concerned that this dosage might be too high, and I’m uncomfortable because I believe it could harm the patient. For patient safety, I recommend we double-check the dosage before administering it.

Explanation:

Option A is correct: The CUS technique is used to address situations where there is a safety concern. It involves clearly stating the concern (the dosage might be too high), explaining why the nurse is uncomfortable (it could harm the patient), and highlighting the safety issue (potential harm to the patient). Offering a solution (double-checking the dosage) demonstrates professionalism and prioritizes patient safety.

Why the other Options are Wrong 

Option B is incorrect: Simply mentioning discomfort without explaining the concern and safety issue does not fully address the situation. It’s important to explain why the nurse is uncomfortable and what the potential safety risk is.

Option C is incorrect: Ignoring the safety issue is not an acceptable response in any clinical setting. Patient safety must always be a priority, and the nurse should address concerns when they arise.

Option D is incorrect: While the nurse mentions discomfort, the statement lacks a clear concern and does not address the potential safety issue directly. A more assertive approach is needed to resolve the concern.

Summary:

The CUS technique helps nurses communicate their concerns effectively by stating the Concern, explaining why they feel Uncomfortable, and addressing the Safety issue involved. This promotes a collaborative approach to ensure patient safety and effective communication within the healthcare team.

The correct answer is:C) The patient assumes responsibility for their health and care, and the hospital documents the decision in the medical record

Explanation:

When a patient decides to leave the hospital against medical advice (AMA), they are taking personal responsibility for their health and well-being. The healthcare provider should inform the patient of the risks of leaving prematurely, document the conversation, and ensure that the decision is clearly recorded in the patient's medical record. This helps protect both the patient and healthcare providers legally.

Why the other options are incorrect:

Option A is incorrect because notifying the family is not a mandatory requirement unless the patient agrees, and it's not part of the AMA process.

Option B is incorrect because the physician does not stop all care; instead, they explain the risks of leaving, offer alternative treatments, and document the AMA decision. The patient is still entitled to leave, but care is not abruptly stopped.

Option D is incorrect because the patient cannot be forcibly restrained simply for leaving AMA. Restraints or detaining a patient without legal grounds or patient consent would be considered a violation of their rights. The patient can leave if they wish, though they should be informed about the potential consequences.

Summary:

When a patient decides to go AMA, they take responsibility for their own health and care, and the decision is thoroughly documented in the medical record. It is important that the patient is made aware of the potential risks of leaving against medical advice.

Correct Answer

Never leave an infant alone.

Test bathwater before placing the infant in it.

Keep small objects out of reach.

Explanation

Infants should never be left unattended, whether on changing tables, in cribs, or other surfaces. Doing so could result in falls, suffocation, or other serious injuries, as infants can move unpredictably. Testing bathwater is necessary to ensure the temperature is safe and comfortable—ideally around 100°F (37.8°C)—to prevent burns or discomfort. Small objects must always be kept out of an infant's reach because infants explore by placing items in their mouths, which poses a serious choking risk.

Why other options are wrong

Place the infant on their stomach to sleep: This is unsafe and significantly increases the risk of sudden infant death syndrome (SIDS). The American Academy of Pediatrics recommends that infants always be placed on their backs to sleep. Stomach sleeping can obstruct the airway and reduce arousal responses, both of which are linked to SIDS. Back-sleeping on a firm surface is the safest sleep position for infants.

Place a pillow in the crib for head support: Pillows and soft bedding should never be used in an infant’s crib. These items increase the risk of suffocation and can obstruct an infant’s breathing if they roll onto them. Even products marketed as “infant pillows” are not recommended for sleep. The safest sleep environment is a firm, flat mattress with a fitted sheet and no additional items in the crib.

The correct answer isB: Elizabeth Kübler-Ross

Explanation:

Elizabeth Kübler-Ross, a Swiss-American psychiatrist, identified the five stages of the dying process in her 1969 book On Death and Dying. These stages—denial, anger, bargaining, depression, and acceptance—describe the emotional responses that individuals typically experience when faced with terminal illness or impending death. Kübler-Ross's work helped bring greater understanding to the psychological and emotional aspects of end-of-life care.

Why the Other Options Are Incorrect:

A. Sigmund Freud

Sigmund Freud is best known for his psychoanalytic theory and concepts like the unconscious mind and the structure of personality (id, ego, and superego). He did not identify the stages of dying.

C. Jean Piaget

Jean Piaget is known for his theory of cognitive development in children, not for identifying stages of dying. His work focused on how children develop their thinking and understanding of the world.

D. Erik Erikson

Erik Erikson is known for his psychosocial development theory, which consists of eight stages across the lifespan. While his work includes stages of human development, he did not focus on the stages of dying.

Summary:

Elizabeth Kübler-Ross identified the five stages of dying: denial, anger, bargaining, depression, and acceptance. These stages are widely used to help understand the emotional responses of patients and families dealing with terminal illness.