Foundations and Adult Health Nursing Test Bank

Correct Answer: B

Rationale: The presentation of a pruritic rash with linear streaks and small, fluid-filled blisters following exposure to poison ivy is characteristic of allergic contact dermatitis. Poison ivy contains an oil called urushiol, which is known to cause this type of skin reaction in individuals who are sensitive to it. The linear streaks are often a result of the plant brushing against the skin. Pemphigus vulgaris is an autoimmune condition characterized by the formation of intraepidermal blisters, typically not associated with linear streaks or exposure to irritants like poison ivy. Bullous pemphigoid is characterized by subepidermal blisters, and herpes zoster presents with a painful rash following reactivation of the varicella-zoster virus in a dermatomal pattern, not typically in linear streaks.

Correct Answer: C

Rationale: It is essential for nurses to record vital signs and notes on a patient as soon as they obtain them. This allows for accurate and timely documentation of crucial information related to the patient's health status. By recording the information promptly, nurses can ensure that they do not forget important details and can provide effective care based on accurate data. Waiting for lunch break or after completing other tasks can lead to delays in documentation, which may compromise patient care and safety. Therefore, the ideal and proper time for recording vital signs and notes is immediately after obtaining them.

Correct Answer: C

Rationale: Total Parenteral Nutrition (TPN) is a method of providing nutrition to patients who cannot or should not obtain their nutrition through regular oral intake. The primary goals of TPN include promoting weight gain, improving nutritional status, maintaining muscle mass, and establishing nitrogen balance. These goals are crucial to support the overall health and well-being of the patient receiving TPN. Enhancing the healing process is an important aspect of TPN as well, but it is not considered one of the primary goals as weight gain, nutritional status, muscle mass, and nitrogen balance are typically the immediate priorities when administering TPN.

Correct Answer: B

Rationale: Teaching the patient diaphragmatic breathing exercises for respiratory support would be the most appropriate intervention to address the symptoms of dyspnea and anxiety in this scenario. Diaphragmatic breathing, also known as belly breathing, focuses on engaging the diaphragm for deep, slow breaths, which can help improve lung expansion and ventilation. This technique can help the patient manage their breathing difficulty and reduce anxiety by promoting relaxation and improving oxygen exchange in the lungs. It empowers the patient with a coping strategy they can use independently to alleviate distressing symptoms at any time. Administering oxygen therapy may be beneficial, but the priority is to teach the patient a technique they can use proactively and routinely. Prescribing benzodiazepines should be considered as an adjunct if non-pharmacological interventions are ineffective in managing anxiety. Referring to a pulmonologist may be necessary for comprehensive evaluation and treatment but may not directly address the immediate symptoms of dyspnea and anxiety.

Correct Answer: B

Rationale: Obtaining informed consent is primarily the responsibility of the physician. Informed consent is a crucial ethical and legal concept in healthcare that requires the healthcare provider, usually the physician, to ensure that the patient understands the proposed treatment, including the risks, benefits, alternatives, and potential outcomes, before agreeing to proceed with the treatment. While other healthcare professionals, such as nurses, nurse managers, anesthesiologists, and midwives, may also play a role in the informed consent process by providing information and clarifying details, it is ultimately the physician who must obtain the patient's informed consent before any treatment or procedure is performed.