Foundations and Adult Health Nursing Test Bank

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

Correct Answer: D

Rationale: When determining the existence of malpractice, intent is not considered as a factor. Malpractice typically involves unintentional actions or negligence rather than a deliberate intent to cause harm. The key factors that are usually considered in a malpractice case include duty (a legal obligation to provide a certain standard of care), causation (the link between the provider's actions and the patient's injury), and the existence of an injury resulting from the provider's actions or omissions. Intent does not play a direct role in malpractice cases, as they are focused on the standard of care provided by the healthcare professional and the harm caused as a result.

Correct Answer: A

Rationale: In delegation, facilitating the professional growth and development of a staff is necessary because it allows team members to gain new skills and experience, leading to overall improved productivity and job satisfaction. This empowers staff and helps them feel more engaged in their work, ultimately benefiting the entire unit. Effective delegation should aim to support individuals in their roles, encourage learning, and build competence, rather than modifying standards of care or only delegating tasks without considering individual growth. Starting delegation from top management to staff-nurse level may not always be practical or efficient, as delegation should be based on competencies and responsibilities. Accountability is indeed a crucial aspect of delegation, as individuals should be held responsible for the tasks they are delegated. However, without providing opportunities for professional growth and development, delegation may not be as effective in achieving organizational goals.

Correct Answer: D

Rationale: The presentation of sudden-onset severe headache, vomiting, and altered mental status, along with the presence of a berry-shaped aneurysm on imaging, point towards a diagnosis of subarachnoid hemorrhage. The most common cause of a subarachnoid hemorrhage is the rupture of a saccular (berry) aneurysm, which commonly occurs at the junction of the anterior communicating artery and anterior cerebral artery. The sudden headache is often described as the "worst headache of my life" and is typically associated with nausea and vomiting. Altered mental status may be present due to the effects of increased intracranial pressure and possible associated brain injury. It is important to promptly diagnose and manage subarachnoid hemorrhage to prevent complications such as vasospasm, rebleeding, and ischemic deficits.

Correct Answer: C

Rationale: Nurse Ace submitting a report to the physician about committing an error in medication demonstrates accountability. Accountability in healthcare refers to the responsibility of individuals to answer for their actions, decisions, and behaviors in the professional setting. By taking ownership of the mistake and informing the physician, Nurse Ace is showing accountability for her actions, ensuring that patient safety remains a priority. Compliance with reporting errors is essential for quality improvement and patient safety in healthcare settings.