Foundations and Adult Health Nursing Test Bank

Correct Answer: C

Rationale: The symptoms described are classic for amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease. ALS is a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord, leading to muscle weakness and atrophy. Patients typically present with weakness, muscle atrophy, fasciculations (muscle twitching), and eventually develop difficulty swallowing and breathing due to involvement of the muscles responsible for these functions. Parkinson's disease (Choice A) is a neurodegenerative disorder characterized by tremors, rigidity, and bradykinesia but does not typically present with muscle atrophy or fasciculations as described in the case. Guillain-Barré syndrome (GBS) (Choice B) is an acute inflammatory condition affecting peripheral nerves, leading to ascending paralysis, which is usually reversible. Myasthenia gravis (Choice D) is an autoimmune disorder that affects neu

Correct Answer: D

Rationale: In cases where a patient becomes seriously ill or is harmed due to receiving the wrong medication, both the nurse and the hospital are likely to be held liable. The nurse is responsible for administering the correct medication to the patient, and any error in this process can lead to harm. The hospital may also be held liable for the actions of its employees, including nurses, under the legal principle of vicarious liability. Additionally, the hospital has a duty to ensure that proper protocols are in place to prevent medication errors, and failure to do so can lead to liability. Therefore, in this scenario, both the nurse and the hospital are likely to share liability for the patient's harm.

Correct Answer: C

Rationale: Normal saline solution is the best choice for cleaning Claudia's eyes with drainage. It is a sterile solution that closely matches the natural pH of the eyes, making it gentle and safe for ocular use. Normal saline can help flush out any debris or discharge in the eye without causing further irritation or complications. On the other hand, hydrochloric acid is a corrosive substance that can cause significant harm if it comes into contact with the eyes. Mineral water may contain impurities that could further irritate the eyes. Soapsuds solution is not recommended for eye cleaning as it can cause irritation and damage to the delicate eye tissues. Therefore, normal saline solution is the most appropriate and safe option for cleaning Claudia's eyes in this situation.

Correct Answer: B

Rationale: The patient's presentation with renal failure, confusion, seizures, asterixis, and a sweet odor to the breath, along with laboratory findings of severe metabolic acidosis, hyperkalemia, and elevated BUN and creatinine levels, is consistent with uremic encephalopathy. Uremic encephalopathy is a neurological complication of acute or chronic renal failure resulting from the buildup of uremic toxins in the blood, leading to various neurological symptoms such as confusion and seizures. The sweet odor to the breath can be attributed to the presence of urea, a waste product that accumulates in renal failure. Other metabolic abnormalities like hyperkalemia and severe metabolic acidosis are also common in renal failure. It is crucial to promptly recognize and manage uremic encephalopathy to prevent further neurological complications.

Correct Answer: A

Rationale: In the case of Romy being diagnosed with small cell lung cancer (SCLC) and undergoing palliative treatment, the most appropriate nursing action is to focus on providing relief from symptoms. Palliative care aims to improve the quality of life for patients with serious illnesses by managing their symptoms, such as pain, shortness of breath, nausea, and other side effects of treatment. As the cancer is advanced and the goal is not curative treatment but rather to keep the patient comfortable, symptom management becomes a priority to ensure Romy's physical comfort and well-being during this difficult time. Providing relief from symptoms is crucial in palliative care to help enhance the patient's quality of life and ensure they are as comfortable as possible.