Foundations and Adult Health Nursing Test Bank

Correct Answer: A

Rationale: The patient's presentation with fatigue, pallor, dyspnea on exertion, low hemoglobin level, decreased MCV, and decreased MCHC are all consistent with iron deficiency anemia. Iron deficiency anemia is the most common type of anemia and occurs when there is insufficient iron available for hemoglobin production. The low hemoglobin level results in symptoms such as fatigue and pallor, while the decreased MCV and MCHC indicate microcytic and hypochromic red blood cells, respectively, which are characteristic of iron deficiency anemia. Vitamin B12 deficiency anemia and thalassemia typically present with a different pattern of laboratory findings and clinical manifestations. Sickle cell anemia is characterized by sickle-shaped red blood cells due to a genetic mutation, and the laboratory findings in sickle cell anemia are different from those seen in the patient described in this scenario.

Correct Answer: C

Rationale: The clinical presentation described with fever, headache, maculopapular rash starting on the face and spreading to the trunk and extremities, along with leukopenia and thrombocytopenia suggests a likely diagnosis of Rocky Mountain spotted fever (RMSF), which is caused by the bacterium Rickettsia rickettsii.

Correct Answer: B

Rationale: Acute otitis media is the most likely condition responsible for this presentation. The sudden onset of severe, unilateral ear pain, diminished hearing, and purulent otorrhea are classic symptoms of acute otitis media. Otoscopic examination revealing a bulging, erythematous tympanic membrane with obscured landmarks further supports the diagnosis. The bulging of the tympanic membrane is due to the accumulation of fluid and pus behind it, causing the characteristic appearance. Treatment typically involves antibiotics to help clear the infection and relieve symptoms. If left untreated, acute otitis media can lead to complications such as perforation of the eardrum or mastoiditis.

Correct Answer: C

Rationale: In the case of Mang Luis, who has been diagnosed with chronic obstructive pulmonary disease (COPD) and is experiencing exacerbation, the most crucial health intervention to include in the teaching plan is to reduce the risk for infection. COPD exacerbations are commonly triggered by respiratory infections such as pneumonia and bronchitis. Preventing infections is essential in managing COPD as they can lead to worsening of symptoms and increased healthcare utilization. Therefore, educating Mang Luis on strategies to reduce the risk of infection, such as proper hand hygiene, avoiding exposure to sick individuals, getting vaccinated, and managing environmental factors, is paramount in his care plan.

Correct Answer: A

Rationale: Nurse Cris should employ the communication technique of summarizing to successfully capture the details of the meeting. Summarizing involves condensing the information provided into a concise and organized form, which would help Nurse Cris remember and retain the key points discussed during the meeting. By summarizing the details, Nurse Cris can ensure that no important information is missed and can also confirm understanding by reflecting back the main points discussed. This technique promotes effective communication by enhancing clarity and reinforcing comprehension.