Foundations and Adult Health Nursing Test Bank

Correct Answer: C

Rationale: Pericarditis is the inflammation of the pericardium, the sac surrounding the heart. Patients with pericarditis typically present with sharp chest pain that worsens with deep breathing, changes in body position, and coughing. The pain tends to improve when the patient leans forward. This characteristic symptom of pericarditis is known as "pleuritic" chest pain. In contrast, stable angina presents as predictable chest pain that occurs with exertion and is relieved by rest or medications. Unstable angina is characterized by chest pain that occurs at rest or with minimal exertion and is considered a medical emergency. Myocarditis involves inflammation of the heart muscle and may present with symptoms such as chest pain, but it does not typically have the characteristic of worsening with deep breathing or changes in body position.

Correct Answer: A

Rationale: Pre-eclampsia is a serious condition that can occur during pregnancy, usually after 20 weeks gestation. It is important to screen for pre-eclampsia early in the pregnancy to monitor and manage the condition effectively. Screening for pre-eclampsia typically begins in the first trimester of pregnancy to identify any risk factors and provide appropriate care for the patient. Therefore, Nurse Vera informing the patient to get screened for pre-eclampsia in the first term of pregnancy is the most appropriate time to start monitoring for this condition.

Correct Answer: B

Rationale: Digoxin is a medication commonly used in the treatment of congestive heart failure because it helps to improve cardiac output and reduce heart failure symptoms. One of the desired effects of digoxin is an increase in urinary output. This is because digoxin helps to improve cardiac function, which can lead to better circulation and increased kidney perfusion. As a result, the kidneys are better able to filter and excrete excess fluid, leading to increased urine output. Therefore, an increase in urinary output indicates that the digoxin is having a positive effect in managing the client's congestive heart failure. The other options, such as increased weight, improved appetite, and increased pedal edema, are not indicative of a desired effect of digoxin therapy.

Correct Answer: C

Rationale: One of the main consequences of hypoxemia, which is low oxygen levels in the blood, is decreased oxygen saturation. Oxygen saturation refers to the percentage of hemoglobin molecules in the blood that are bound to oxygen. When there is insufficient oxygen in the blood due to hypoxemia, the oxygen saturation levels will drop. This can lead to symptoms such as shortness of breath, confusion, rapid heart rate, and ultimately can result in tissue damage if not corrected promptly. Monitoring oxygen saturation levels is crucial in the immediate post-operative phase to ensure adequate ventilation and oxygenation for the patient's recovery.

Correct Answer: A

Rationale: The development of autoantibodies such as antinuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies in systemic lupus erythematosus (SLE) is primarily attributed to a loss of self-tolerance. Self-tolerance refers to the immune system's ability to recognize and differentiate self-antigens from foreign antigens. In individuals with SLE, there is a breakdown in immune tolerance mechanisms, leading to the production of autoantibodies against self-antigens like nuclear components (e.g., DNA, RNA, histones). This loss of self-tolerance results in the immune system targeting and attacking its tissues, leading to the systemic inflammation and tissue damage characteristic of SLE. The presence of elevated levels of ANA and anti-dsDNA antibodies in this patient suggests an autoimmune response against nuclear material, further supporting the role of self-tolerance breakdown in SLE