Foundations and Adult Health Nursing Test Bank

Correct Answer: A

Rationale: The correct instruction that the nurse should include in patient education about phosphate binder therapy is to "Take phosphate binders with meals." Phosphate binders are medications given to patients with chronic kidney disease to help control high phosphate levels in the blood. Taking phosphate binders with meals allows them to bind to the phosphorus present in the food, reducing its absorption in the body. This helps to lower blood phosphate levels effectively. Instructing the patient to take phosphate binders with meals ensures optimal binding of phosphorus from the diet, which is crucial for managing phosphate levels in patients with chronic kidney disease.

Correct Answer: A

Rationale: Attention deficit hyperactivity disorder (ADHD) is characterized by inattentiveness, overactivity, and impulsiveness. Individuals with ADHD may have difficulty paying attention, completing tasks, sitting still, or controlling their impulses. Mental retardation (now referred to as intellectual disability) is a separate condition characterized by limitations in intellectual functioning and adaptive behaviors. While individuals with ADHD may experience difficulties in school or work due to their symptoms, ADHD itself does not indicate mental retardation.

Correct Answer: C

Rationale: The submandibular gland is located inferior and posterior to the mandible. It produces a mixed type of saliva, which is primarily serous (enzyme-rich) but also contains some mucous components. This gland plays a significant role in digestion, as its serous saliva contains enzymes such as amylase that help break down carbohydrates in the mouth before they reach the stomach.

Correct Answer: A

Rationale: Nonverbal communication is as strong in conveying information because the nurse can effectively interpret and understand gestures made by the individual they are interacting with. Gestures such as hand movements, facial expressions, eye contact, and body posture can communicate a lot of information without the use of words. By observing these nonverbal cues, nurses can better comprehend the emotions, needs, and feelings of their patients or colleagues, leading to more effective communication and overall better care. Nonverbal communication, including gestures, plays a significant role in creating a holistic understanding of individuals' messages beyond just words.

Correct Answer: A

Rationale: Lactulose is the most effective nursing intervention in preventing and managing hepatic encephalopathy in patients with cirrhosis. Lactulose works by promoting the elimination of ammonia in the colon through its laxative effect, thereby reducing ammonia levels in the blood. High ammonia levels are associated with the development of hepatic encephalopathy. By administering lactulose as prescribed, nurses can help reduce the risk of encephalopathy and manage symptoms effectively. Monitoring serum ammonia levels is important in assessing the effectiveness of lactulose therapy, but administering lactulose is the primary nursing intervention in this situation. Dietary protein restriction is also commonly recommended; however, lactulose administration is the most vital intervention in this scenario. Additionally, encouraging increased fluid intake is important for overall liver health but is not as specific to preventing and managing hepatic encephalopathy as administering lactulose.