Foundations and Adult Health Nursing Test Bank

Correct Answer: D

Rationale: Incompetent cervix, also known as cervical insufficiency, is the most likely cause of the symptoms described. Incompetent cervix is a condition where the cervix begins to dilate and efface prematurely, typically in the second trimester, without contractions or labor. This can lead to painless cervical dilation and bulging of the amniotic sac into the vagina, which can cause vaginal bleeding and crampy abdominal pain. It is a leading cause of second-trimester pregnancy loss. Treatment may involve a cervical cerclage, a surgical procedure where the cervix is stitched closed to provide additional support.

Correct Answer: C

Rationale: Fowler's position is the correct position to help a patient experiencing breathing difficulty. In Fowler's position, the patient is sitting up at a 45- to 60-degree angle with the legs either straight or bent. This position allows for maximum chest expansion, helping to improve ventilation and oxygenation. It is commonly used to assist patients with respiratory distress, including difficulties with breathing. Placing the patient in Fowler's position can alleviate the feeling of breathlessness and facilitate easier breathing by promoting better lung expansion.

Correct Answer: B

Rationale: Digoxin is a medication commonly used in the treatment of congestive heart failure because it helps to improve cardiac output and reduce heart failure symptoms. One of the desired effects of digoxin is an increase in urinary output. This is because digoxin helps to improve cardiac function, which can lead to better circulation and increased kidney perfusion. As a result, the kidneys are better able to filter and excrete excess fluid, leading to increased urine output. Therefore, an increase in urinary output indicates that the digoxin is having a positive effect in managing the client's congestive heart failure. The other options, such as increased weight, improved appetite, and increased pedal edema, are not indicative of a desired effect of digoxin therapy.

Correct Answer: B

Rationale: Being assertive means expressing one's thoughts, beliefs, and feelings in a confident and respectful manner while also considering the perspective of others. It does not involve pushing control on others. Assertive individuals do not impose their beliefs on others but express themselves clearly and confidently, respecting the opinions of others. So, standing up for what one believes in can be assertive, but pushing control on others is not a characteristic of assertiveness.

Correct Answer: A

Rationale: Of the options provided, documenting objective, observable findings such as large bruises on the thigh upon assessment is the most defensible entry in court. This type of entry is based on the nurse's direct observation and assessment of the patient's physical condition, which can be corroborated by other healthcare providers or evidence. It provides clear, factual information without making assumptions or subjective judgments. In court, this type of documentation can help support the nurse's credibility and reliability as a witness.