Adult Health Nursing Test Banks

Correct Answer: A

Rationale: The most appropriate nursing intervention to alleviate breast engorgement and discomfort in a breastfeeding client is to encourage frequent breastfeeding or pumping sessions. Engorgement occurs when the breasts become overly full of milk, causing them to become swollen, firm, and painful. By ensuring that the baby breastfeeds frequently, the client can effectively empty the breasts, which helps to relieve engorgement and discomfort. Encouraging the client to breastfeed on demand and ensuring proper latching can help prevent further engorgement issues. Pumping can also be useful if the baby is unable to feed directly from the breast or to relieve engorgement between feedings. This intervention addresses the root cause of the problem and promotes the client's comfort and breastfeeding success. Applying cold packs, using a supportive bra or breast binder, and administering oral analgesics may provide some relief for discomfort but do not address the underlying issue of engorgement.

Correct Answer: A

Rationale: The presentation of well-demarcated, hypopigmented macules with fine scaling on the trunk and proximal extremities is classic for tinea versicolor. Tinea versicolor is a common superficial fungal infection caused by Malassezia spp., which leads to hypo- or hyperpigmented patches on the skin. The condition often occurs in individuals with increased sebum production due to factors such as hot and humid climates, sweating, and oily skin. History of sun exposure and outdoor activities is also commonly reported by patients with tinea versicolor. Treatment usually involves antifungal medications applied topically or taken orally to eliminate the fungus. Differentiating tinea versicolor from other skin conditions, such as vitiligo, pityriasis rosea, or seborrheic keratosis, is important for appropriate management.

Correct Answer: C

Rationale: In this situation, it is crucial for the nurse to inform the surgeon immediately and request corrective action. Maintaining a sterile field during surgical procedures is essential to prevent infections and ensure patient safety. Any break in sterile technique should be addressed promptly to prevent any potential harm to the patient. By informing the surgeon immediately, corrective action can be taken promptly to maintain the sterility of the surgical field and minimize the risk of complications. Reporting the incident to the surgeon also allows for immediate intervention and re-education of the team member involved in the break in sterile technique.

Correct Answer: B

Rationale: The nurse's best response to a patient expressing fear of the unknown regarding an upcoming surgical procedure is to provide the patient with accurate information about the surgical procedure and what to expect. This approach empowers the patient with knowledge and helps alleviate anxiety by demystifying the unknown. By educating the patient about the procedure, potential risks, and postoperative care, the nurse can help the patient feel more prepared and in control of the situation. It is crucial for healthcare providers to address patient fears with compassion, understanding, and information to support the patient through the surgical process.

Correct Answer: A

Rationale: The liver is responsible for secreting bile, which aids in the emulsification and digestion of fats. Bile is produced by the liver and is stored and concentrated in the gallbladder before being released into the small intestine to help with the breakdown of fats during the digestion process. The gallbladder functions as a storage organ for bile produced by the liver. The pancreas secretes digestive enzymes and bicarbonate to aid in the digestion process, while the spleen is mainly involved in immune function and blood storage.