Foundations and Adult Health Nursing Test Bank

Correct Answer: C

Rationale: Total Parenteral Nutrition (TPN) is a method of providing nutrition to patients who cannot or should not obtain their nutrition through regular oral intake. The primary goals of TPN include promoting weight gain, improving nutritional status, maintaining muscle mass, and establishing nitrogen balance. These goals are crucial to support the overall health and well-being of the patient receiving TPN. Enhancing the healing process is an important aspect of TPN as well, but it is not considered one of the primary goals as weight gain, nutritional status, muscle mass, and nitrogen balance are typically the immediate priorities when administering TPN.

Correct Answer: B

Rationale: The primary objective of a birth plan is to provide a pregnant woman the opportunity to outline her wishes and preferences regarding her labor, delivery, and postpartum care. It allows the mother-to-be to communicate her desires to the healthcare team in advance, ensuring that her preferences are considered and respected during the birthing process. A birth plan typically covers various aspects such as pain management options, who she wants present during labor, interventions she may want to avoid, plans for after birth care, and any other specific requests she may have. Ultimately, a birth plan aims to empower the woman to have a more personalized and satisfying birth experience by actively involving her in the decision-making process.

Correct Answer: D

Rationale: Before initiating any oxygen therapy, it is crucial for the nurse to first assess the patient's condition. This step allows the nurse to determine the patient's oxygen saturation levels, respiratory rate, lung sounds, and overall respiratory status. Understanding the patient's baseline condition helps in selecting the appropriate oxygen delivery method and flow rate that will best meet the patient's needs. Additionally, assessing the patient's condition allows the nurse to monitor the effectiveness of the oxygen therapy and make any necessary adjustments throughout the treatment process. Therefore, assessing the patient's condition is the necessary first step in providing safe and effective oxygen therapy.

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: 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